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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings to prevent swelling in your legs. The Plan denied your request. The Plan says gradient compression stockings (A6530) do not meet the definition of a surgical dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on April 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.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 an independent laboratory; 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 forthe drug testing rendered to the enrollee on April 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 1, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 27, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed.
You asked the Plan to pre-approve the semi-electric hospital bed. You say that it is a medical necessity that the enrollee receives a hospital bed with railings due to having a very high fall risk with unsteady gait. The Plan denied your request. The Plan says the documentation provided does not meet the medically necessary criteria.
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 the semi-electric hospital bed. Our reviewer says that this enrollee does not meet the medical necessity criteria for a semi-electric hospital bed. Our physician reviewer found the enrollee's condition does not require position of the body in ways not feasible in an ordinary bed. The enrollee does not require frequent or immediate changes in body position. The enrollee's condition does not require special attachments that cannot be fixed and used on an ordinary 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 the semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Flexitouch pneumatic compression device and appliances. You asked the Plan to providea pneumatic compression device (E0652) and appliances (E0667). You say that the Flexitouch pneumatic compression device is an essential part of the enrollee's long-term effective home treatment.The Plan denied your request. The Plan says there is no documentation of chest, trunk, or abdominal swelling, or of a 4 week trial with a basic pump.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. Atleast 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 providea Flexitouch pneumatic compression device and appliances.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an acute inpatient hospital stay provided from February 22, 2019 to February 27, 2019.
You asked the Plan to pay for an acute inpatient hospital stay. You say that this inpatient admission was medically necessary for the patient and therefore the denial should be overturned. In addition, this inpatient admission is indicated as medically necessary by the nationally accepted clinical criteria for inpatient admission. Review the following clinical appeal along with the enclosed clinical information and approve the authorization for this patient's medically necessary inpatient care. The Plan denied your request. The Plan says that the acute inpatient hospital stay was not medically necessary. Based on the clinical records provided, participant's care did not meet medical necessity criteria for acute inpatient hospital level of care. Participant care needs could have been provided in an alternative care level such as observation status or acute nursing facility. A short period of observation care and the participant could have returned home to residence's sub-acute nursing facility for observation and continued medical management.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 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 an acute inpatient hospital stay. Our reviewer says that the service was medically necessary. Our physician reviewer found the enrollee presented to the emergency department (ED) on February 22, 2019 with left sided weakness. She was found to have a hematocrit level of 21. She was admitted to the medical floor and evaluated by Gastroenterology. She received a transfusion of red blood cells. Her condition stabilized and improved and she was discharged on February 27, 2019 when considered medically stable. The review has determined that the documentation supports that the requested services February 22, 2019 through February 27, 2019 were necessary and reasonable to meet the participant's needs and to improve and maintain the participant's overall health status. The requested services were not experimental or cosmetic. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an acute inpatient hospital stay have been met. Therefore, we decided that the Plan has to pay for an acute inpatient hospital stay provided from February 22, 2019 to February 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on May 15, 2019.
You asked the Plan to pay for the testing. You say that this was medically necessary as per the ordering physician. The Plan denied your request. The Plan says the service was billed incorrectly, as train of four is considered a bundled procedure.
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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure." We find that CPT code 95999 is not supported in the medical record. Specifically, this is considered a bundled procedure, and cannot be paid separately. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on May 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator (CPT Code K0606) provided on July 23, 2019.You asked the Plan to waive the coinsurance for the DME. You say that you reported numerous times to the physician that the DME was malfunctioning.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received automatic external defibrillator (CPT Code K0606)provided on July 23, 2019. You asked for 20% coinsurance for DME. 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 automatic external defibrillator (CPT Code K0606) provided on July 23, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient clinic visit and injection provided on August 29, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient clinic visit and injection. You say that you followed all the rules. You say that you had to wait three months before going back to work due to the run around from the insurance company.The Plan denied yourrequest. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for these services.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. ThePlan 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 foroutpatient clinic visit and injection provided on August 29, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 21, 2019 through March 24, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you believe this was a continuation of another stay. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on March 21, 2019 and discharged on March 24, 2019. You were asked to pay a $370 copayment per day from March 21, 2019 through March 23, 2019, days 1-3 of your inpatient hospital care. You were discharged on March 24, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $370 copayment per day required for days 1-5 each time you are admitted to the hospital. 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 from March 21, 2019 through March 24, 2019 provided by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the aflibercept injection you received on October 25, 2019.
You asked the Plan to waive the cost share for the injection. You say that you were not told the copay would be so high. The Plan denied your request. The Plan says the cost share was applied based on your plan benefits.
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 Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B prescription drugs 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 cost share for the aflibercept injection you received on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 11, 2019.You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to set up the pump and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI's provided on July 19, 2019 and July 22, 2019.You asked the Plan to waive the copayment forthe MRI's. You say that you were informed the first scan should have been stopped so the order could be changed. You say that you shouldn't have to pay for two MRI's.The Plan denied your request. The Plan says the copayments applied correctly.The rules say aplan 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 $275 copayment for each advanced imaging service. You have been asked to pay $176.29, which is less than the standard $275 copayment for each MRI. The total amount you owe is $352.58 ($176.29/MRI x 2 MRI's = $352.58). The MRI's fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that two MRI's were performed. 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 forthe MRI's provided on July 19, 2019 and July 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAustedo.You asked the Plan to pre-approveAustedo. You say that Austedo has started toimprove signs and symptoms of tardive dyskinesia.The Plan denied your request. The Plan says this medication does not fall under the Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveAustedo..Benefits for Austedomay beavailable under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve front wheeled walker with seat (E0143).You asked the Plan to pre-approvethe walker with seat. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says the requested item services the same purpose as an item already received. Records show a front wheeled walker with seat was received on September 19, 2018.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have front wheeled walker with seat. front wheeled walker with seat serves the same purpose as the walker with seat.Therefore, we decided that the Plan does not have to pre-approvefront wheeled walker with seat (E0143).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152 and 99153) provided on September 4, 2019 through September 5, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records do not indicate the presence of an independent trained observer (99152) and payment for CPT code 99153 is included in payment to the facility.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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT codes 99152 and 99153 are not supported in the record. Specifically, CPT code 99152 requires the presence of an independent trained observer. The records do not indicate the presence of an independent trained observer. CPT code 99153 has been billed with POS 21. The payment for this service is included in the payment to the facility. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152 and 99153) provided on September 4, 2019 through September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist office visit or the x-ray provided on September 16, 2019.You asked the Plan to waive the copayments forthe specialist office visit and the x-ray. You say that this was supposed to be a covered expense. You say you were told this visit fell outside of the 90-day period associated with the surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each Medicare-covered visit with an in-network specialist and a $35 copayment per day, per provider for Medicare-covered in-network x-ray services. You have been asked to pay a $50 copayment for the specialist office visit and a $28.75 copayment, which is less than the standard copayment, for the x-ray. The specialist office visit falls within the "Physician/Practitioner services including office visits" benefit category. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.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 copayments forthe specialist office visit or the x-ray provided on September 16, 2019.