Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sales tax (S9999) applied to services received on January 29, 2020.
You asked the Plan to pay for sales tax. You say that you urgently needed this service. The Plan denied your request. The Plan says sales tax is not payable under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that MACs do not make any additional payment for sales taxes and do not make adjustments in fees to reflect local changes in tax rates. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax (S9999) applied to services received on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions provided on May 6, 2019.
You asked the Plan to pay for the extractions. You say that you do not have dental coverage. You also say that
these services were to be considered medically necessary and billed to your medical coverage. The Plan denied
your request. The Plan says this service is not a covered benefit. The Plan also says that you do not have dental
coverage.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the two extractions provided on
May 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are appealing. The Plan denied your request. The Plan says these supplies are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the superselective catheter placement of the renal artery for
renal angiography (36254) provided on February 25, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says this service is not supported in the medical
records provided.
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 36254 is superselective catheter placement (one or more
second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal
angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image
postprocessing, permanent recording of images, and radiological supervision and interpretation, including
pressure gradient measurements when performed, and flush aortogram when performed; bilateral.
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 this service. Our reviewer says that the billed
service does not meet criteria for payment. Our physician reviewer found that the enrollee was noted to have
undergone left renal artery vascular intervention. There is no evidence that right renal artery vascular
intervention was performed. Therefore, the billing of CPT code 36254, which claims bilateral intervention, is
not supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pay for the superselective catheter placement of the renal artery for renal angiography (36254) provided
on February 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 22, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee has continued to improve from SNF care and should be allowed to stay. The Plan denied your request. The Plan says the enrollee's medical condition and level of function have improved and daily skilled services are no longer needed to maintain her condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who sustained a left femur fracture on 4/26/2020. She was admitted to the hospital and had surgical repair of the femur fracture on 04/27/2020. Her post-operative course was complicated by delirium and she transferred to a skilled nursing facility for physical and occupational therapy rehabilitation on 05/01/2020. The enrollee is walking 40 to 50 feet with a rolling walker with contact guard assistance as of 05/22/2020. She is requiring minimum assistance with upper body and moderate assistance with lower body activities of daily living. Further therapy notes of 05/25/2020 report the enrollee was not willing to participate with therapy and repeatedly asked to go back to bed. She is reported to be medically stable. The submitted records do not show a need for daily skilled nursing or therapy services. Less than daily skilled services in a lower level of care would
be appropriate. 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95937, CPT 95908) provided on January 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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. In this case, the CPT Code Manual definition of code 95937 is "Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method". The CPT code Manual definition of code 95908 is "Nerve conduction studies; 3-4 studies". We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT codes 95937 and 95908 is not supported by the records provided. Our coding reviewer found that the medical records submitted do not include documentation of "Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method", being performed on January 13, 2020. The medical records document that Train of Four Testing/Monitoring was performed on January 13, 2020. It is inappropriate to use CPT code 95937 for Train of Four testing. Additionally, the technical report in the medical records provided does not include documentation on "nerve conduction studies; for 3-4 studies", therefore this service cannot be validated as being performed on January 13,2020. The use of pedical screws, as noted in the medical record, does not meet definition criteria for CPT code 95908. We looked at this coder's review, the file, and Medicare rules. 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 services (CPT 95937, CPT 95908) provided on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the removal of malignant skin provided on August 16, 2019.
You asked the Plan to waive the coinsurance for the removal of malignant skin. You say that you disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 10% coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received the removal of malignant skin on August 16, 2019. The total allowed amount is $858.46 and 10% of that is $85.85. You have been asked to pay the total coinsurance amount of $85.85 for the removal of malignant skin. The removal of malignant skin falls within the outpatient surgery and other medical 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 coinsurance for the removal of malignant skin provided on August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
You asked the Plan to pre-approve a semi-electric hospital bed. The Plan denied your request. The Plan says that there is no documentation why the enrollee needs this bed or why a standard bed is insufficient.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed. Our reviewer says that a semi-electric hospital bed is not medically reasonable and necessary for the enrollee in this case. There is no documentation that the patient's condition requires positioning of the body in ways not feasible in an ordinary bed. There is no documentation that the patient requires frequent changes in body position or has a need for immediate changes in body position. There is no documentation that the patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. Our physician reviewer found the enrollee's condition does not meet Medicare criteria for a semi-electric hospital bed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-rays provided on October 31, 2019.
You asked the Plan to pay for the physician services. You say that the enrollee was no longer enrolled in hospice on the date of service. The Plan denied your request. The Plan says The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 21, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit and x-rays provided on October 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0428, A0425) provided June 3, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that 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 $265 copayment for ambulance services. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the ambulance 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 an ambulance transport (A0428, A0425) provided June 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sanitizer, gloves, masks, and alcohol.
You asked the Plan to pre-approve sanitizer, gloves, masks, and alcohol. You say that the Plan should provide
these items. The Plan denied your request. The Plan says these items are not covered as they are not used to
treat a medical condition.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. The items are
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 sanitizer, gloves, masks, and alcohol.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub for the enrollee.
You asked the Plan to pre-approve a walk-in bathtub. You say that the enrollee is having increasing difficulty using a regular bathtub. The Plan denied your request. The Plan says that hygienic equipment is not covered as it is not primarily medical in nature.
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 a walk-in bathtub for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on December 16, 2019 by a non-contracted provider.
You asked the Plan to pay for the dental services. You say that you thought the services were emergent and necessary. The Plan denied your request. The Plan says you do not have out-of-network benefits and the provider opted out of Medicare.
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. This provider does not participate with the Plan and they also opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on December 16, 2019 by a non-contracted provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the enrollee does not have an approved indication for use.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our physician reviewer found that Keytruda was requested to treat recurrent, progressive glioblastoma multiforme (GBM.) The submitted documentation does not indicate whether testing for microsatellite instability or mismatch repair has been done. Keytruda is not FDA approved for GBM. The drug is not supported in any of the CMS approved compendia for GBM. This reviewer did not find any supportive citations in a PubMed search. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Therefore, the requested drug is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) and fundus photography with interpretation and report (92250) provided on January 21, 2020 by an out-of-network provider.
You asked the Plan to pay for the vision care. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits. 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 claim for your routine vision services paid for the same date of service. However, this provider is not in-network with your medical policy. 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. 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 ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) and fundus photography with interpretation and report (92250) provided on January 21, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says you do not have a qualifying diagnosis.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lotion, eye drops, vitamins, denture cleanser, and mouthwash.
You asked the Plan to pre-approve over-the-counter items. You say that the enrollee needs these brand name items. The Plan denied your request. The Plan says the items do not meet criteria to be classified as durable medical equipment.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and these items are over-the-counter items. The enrollee has a supplemental benefit for OTC items. Therefore, we decided that the Plan does not have to pre-approve lotion, eye drops, vitamins, denture cleanser, and mouthwash.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed above 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the acute hospital. You were at a maximal assist for bed mobility and transferred using a stand up lift. You required varying assist with activities of daily living (ADLs) and received diathermy to your shoulders. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair, a raised toilet seat, and a grab bar.
You asked the Plan to pre-approve a shower chair, a raised toilet seat, and a grab bar. You say that you are unable to bathe or shower without help due to only having one leg. You say that the requested items are not hygienic items but are something that you need in order to take care of yourself. You stated that the items are urgently needed. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs, raised toilet seats, and grab bars are not covered because they are not primarily medical in nature. While a shower chair, a raised toilet seat, and a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair, a raised toilet seat, or a grab bar