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

We decided that the Plan does not have to pay for foot orthotics provided on January 29, 2021.
You asked the Plan to pay for foot orthotics. You say that the claim has been pre-approved. The Plan denied
your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 29,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit (99334) and a removal of nails (11721) provided on May 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a rest home visit and removal of nails. You say that an authorization was not obtained prior to seeing this patient since it is the nursing facilities responsibility to get authorizations. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a rest home visit (99334) and a removal of nails (11721) provided on May 13, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99283) provided on February 27, 2021.
You asked the Plan to pay for code 99283. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that code 99283 is not supported in the record. Specifically, the claim was billed with diagnosis code Z00.00, which indicates an encounter for general adult medical examination without complaint, suspected or reported diagnosis. This diagnosis code does not support an emergency medical condition for emergency department services. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99283) provided on February 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve new eyeglass frames (V2020).
You asked the Plan to pre-approve new eyeglass frames. You say that you need to renew your driver's license but failed the vision exam. You also say that you were told you need new eyeglasses, but you cannot wait till
your next allowance benefit is available in October 2021. The Plan denied your request. The Plan says you exhausted your benefit allowance.
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 contract says that the Plan covers one routine eye exam every year; and up to $300 for eyeglasses (frames and lenses) or up to $300 for contact lenses every two years. We looked at the file and the Plan's rules. The records show that you exhausted your maximum benefit allowed amount on October 15, 2019. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames have not been met. Therefore, we decided that the Plan does not have to pre-approve new eyeglass frames (V2020).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 25, 2020, through December 27, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an inpatient admission 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 25, 2020, through December 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches, which are included in the allowance of these power options.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records report that the enrollee is independent with feeding and has 3-3+/5 left upper extremity strength thus indicating her strength and upper extremity function are adequate to control the power options with their own switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility for the 
enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 

The enrollee was admitted for chest pain and congestive heart failure. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided February 9, 2021, through February 15, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the inpatient stay was a result of a mistake made during a scheduled surgery and you should not be responsible for the cost. The Plan denied your request. The Plan says the copayment has been applied correctly. Your grievances are being handled separately by the Plan.
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 $280 copayment each day for days 1 to 6 for Medicare-covered hospital care. You have been asked to pay a total of $1,120 ($280 copayment x 4 days) for the inpatient hospital stay. This
hospital stay falls within the Inpatient Hospital 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 the inpatient hospital stay provided February 9, 2021, through February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on February 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional trips to attend your physician and physical therapy visits. The Plan denied your request. The Plan says the benefit has been exhausted and additional trips are not approved.
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 40 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 provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neuromonitoring services (95938, 95937, 95941) provided January 14, 2020.
You asked the Plan to pay for the diagnostic services. You say that there are no in network neuromonitoring providers in the area, due to the nature of the surgery, this service was medically necessary for the welfare of the enrollee. The Plan denied your request. The Plan says payment for these services was included in the
payment to the facility. Billing these services separately represents a duplication of effort and overlap of services.
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 enrollee received these services during another procedure. The facility charges include the technical component of intraoperative neurophysiology monitoring services. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for intraoperative neuromonitoring services (95938, 95937, 95941) provided January 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you cannot do anything on your own. The Plan denied your request. The Plan says there are no noted skilled nursing or therapy needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and uncomplicated wound care. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you are at a contact guard assist level with functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with your Primary Care Provider (PCP) on February 19, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that you do not believe that talking to your doctor for five minutes is comparable to an office visit, so you would like the copayment waived. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for telehealth visits with your PCP.
You have been asked to pay a $10 copayment for the telehealth visit. This copayment applies regardless of the length of the telehealth visit. 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 telehealth visit you had with your Primary Care Provider (PCP) on February 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Ceftazidime injection you received on February 20, 2021.
You asked the Plan to waive the coinsurance for the Ceftazidime injection. You say that you are being billed for a clogged midline when you did not have one. You stated that you should not be charged for this service. The Plan denied your request. The Plan says this coinsurance was charged correctly. The Plan says that your medical records show that these IV antibiotics were properly ordered by the attending provider.
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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Ceftazidime injection. The Ceftazidime injection falls within the Medicare Part B drugs benefit category. This coinsurance applies regardless of the reason you were given the drugs. 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 coinsurance for the Ceftazidime injection you received on February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services rendered on October 6, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 99100 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status
indicator of B and is not separately payable. Therefore, we decided that the Plan does not have to pay for the
special anesthesia services rendered on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the and fracture treatment provided on September 15, 2020.

You asked the Plan to pay for closed treatment of clavicular fracture; without manipulation (23500RT). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include documentation of closed treatment of clavicular fracture, right side, therefore the billed service cannot be verified.

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 code 23500RT is not supported in the medical record. Specifically, the diagnosis code, appeal letter and medical records show the fracture was on the left side. Based on this information, we decided that Medicare rules for coverage of closed treatment of clavicular fracture; without manipulation (23500RT) have not been met. The claim cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for the fracture treatment provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.

You asked the Plan to pre-approve a grab bar. You say that your physician confirmed this equipment necessary to avoid falls. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (83540) provided on February 10, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
not reported with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes are covered for iron
studies.
We looked at the file and Medicare rules. Only those diagnosis codes listed in NCD 190.18 are covered for iron
studies. In this case, the billed diagnosis codes are not covered for the requested iron testing. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for the lab services (83540) provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new pair of eyeglasses to be purchased from an out-of-network (OON) provider.

You asked the Plan to pre-approve a new pair of eyeglasses. You say that you are on a very tight income and cannot afford the cost of eyeglasses with the network provider. You also say you can get glasses for half the cost from a different provider. The Plan denied your request. The Plan says eyeglasses will only be covered when services are received from a provider in the specified vision network.

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 contract says you receive one pair of eyeglasses every two calendar years from participating network providers.

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve a new pair of eyeglasses to be purchased from an out-of-network (OON) provider.