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

We decided that the Plan does not have to pre-approve calf compression wraps.
You asked the Plan to pre-approve calf compression wraps. You say that you would like the Plan to provide calf compression wraps. The Plan denied your request. The Plan says there is no documentation that the member has a wound or ulcer to the lower extremities.
The Plan must follow Medicare rules. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record shows the calf compression wraps are not for a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression bandages can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve calf compression wraps.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lens coating (V2784) for eyeglasses purchased on February 23, 2021.
You asked the Plan to pay for the lens coating. You say that you do not agree with this denial. The Plan denied your request. The Plan says lens enhancements are not covered by your supplemental vision benefit.
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. We looked at the file and the Plan's rules. The Plan's contract does not offer an additional provision for coverage of lens enhancements with routine eyewear. Based on this information, we decided that the Plan's rules for coverage of the lens coating have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lens coating (V2784) for eyeglasses purchased on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 13,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you were never told that you
would owe a copayment. 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 a $10
copayment for specialist services.
You have been asked to pay a $10 copayment for a specialist visit. A specialist visit falls 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 visit provided on January 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custodial care services.
You asked the Plan to pre-approve the custodial care services. You say that you need help bathing, getting dressed, being lifted, and being taken to appointments. You also say that your wife cannot lift more than 30 pounds. The Plan denied your request. The Plan says custodial services are not a covered Medicare benefit, and cannot be approved.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve custodial care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750), and post and core in addition to crown (D2954).
You asked the Plan to pre-approve a crown, and post and core in addition to crown. You say that you want the Plan to pay for this service. 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 pre-approve a crown (D2750), and post and core in addition to crown (D2954).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Retacrit is only covered for certain indications. 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 Retacrit. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the requested Retacrit is being not being used under the medically-accepted standard(s) of: enrollee's iron status has been evaluated and sufficient iron levels will be maintained prior to initiation of therapy and continuation of therapy (i.e. transferrin saturation should be at least 20% OR ferritin at least 100ng/ml).
The documentation does not support that the enrollee has a diagnosis/condition that would be covered for Retacrit. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73560) provided on January 29, 2021.

You asked the Plan to pay for an x-ray. You say that these were separate services. The Plan denied your request. The Plan says this cannot be paid separately.

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, we have confirmed that code 73560 has a bundled relationship with code 73564 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (73560) provided on January 29, 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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 28, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you were assaulted which led to the hospital stay and cannot afford the 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 a $295 copayment, per admission, for inpatient hospital care.

You have been asked to pay a $295 copayment for inpatient hospital care. Inpatient hospital care 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 inpatient hospital care provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on February 17, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the services provided. You say that the facility is responsible for obtaining prior authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The 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 rest home visit provided on February 17, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation services provided on October 21, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Electrical stimulation, when provided by a chiropractor is not covered by Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pay for the electrical stimulation services provided on October 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound of the breast provided on
November 19, 2020.
You asked the Plan to waive the deductible for ultrasounds of the breast. You say that you should have met
your deductible at the time of this visit. The Plan denied your request. The Plan says the deductible you are
being charged is correct.
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 $600
deductible for your covered medical services from in-network and out-of-network providers.
The service at issue is subject to the Plan deductible of $600. The allowed amount of the claim is $101.07 for
each ultrasound, resulting in a deductible obligation of $101.07, for a total of $202.14 ($101.07 + $101.07 =
$202.14). The record shows that at the time this claim was processed, $347.66 of the $600 deductible had been
met ($347.66 + $202.14 = $549.80). This left you with a remaining deductible amount of $50.20 ($600 -
$549.80 = $50.20). The Plan has followed Medicare rules by clearly disclosing in the contract that there is $600
deductible for covered medical services from in-network and out-of-network providers. 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 deductible for two (2) ultrasounds of the breast (76641 RT, 76641 LT) provided on
November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a consultation (D9310) provided on November 17, 2020.

You asked the Plan to pay for a limited oral evaluation, and a consultation. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says that the services at issue are not covered benefits. You were not enrolled with the optional supplemental benefit on the date of service.

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 a limited oral evaluation (D0140), and a consultation (D9310) provided on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on September 3, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you have been in compliance for over three years and request that the Plan pay for the device and supplies. 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 20% coinsurance for DME and related supplies. You received DME and related supplies on September 3, 2020. The total allowed amount is $333.51 and 20% of that is $66.71.
You have been asked to pay the total coinsurance amount of $66.71 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on September 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from January 7,
2021, through January 26, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that this is related to COVID and
you should not be charged a copayment. The Plan denied your request. The Plan says the copayments applied
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 $40
copayment for physical therapy at an in-network outpatient hospital.
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is
$160 ($40/visit x 4 visits = $160). Physical therapy falls within the "Outpatient rehabilitation services" benefit
category. The records show the physical therapy was provided due to muscle weakness. 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 physical therapy provided from January 7, 2021, through January 26,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hammertoe correction services coded 28285 provided on November 16, 2020.

You asked the Plan to pay for the hammertoe correction services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 28285 is correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy).

We find that CPT code 28285 is not supported in the medical record. Specifically, operative report did not include documentation of a correction of the hammertoe (interphalangeal fusion, partial or total phalangectomy); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the hammertoe correction services have not been met. Therefore, we decided that the Plan does not have to pay for the hammertoe correction services coded 28285 provided on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0657, E0668).
You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0657, E0668).
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 the enrollee needs IRF services. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of 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 the patient was admitted for. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supply allowance for therapeutic CGM (CPT code K0553) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT code K0554), for the enrollee.
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve supply allowance for therapeutic CGM (CPT code K0553) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT code K0554), for the enrollee.