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

We decided that the Plan has to pay for anesthesia services (01202) provided on November 7, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because this claim has been denied as a duplicate in error. The Plan denied your request. The Plan says that this claim was an exact duplicate of another claim that has been processed and paid.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The record does not include evidence of the taxonomy for the provider who rendered the anesthesia service. The record does not indicate that the provider who has been paid for these services was involved in this procedure. Therefore, we decided that the Plan has to pay for anesthesia services (01202) provided on November 7, 2019.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met in another setting.
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 the patient is currently undergoing treatment at an acute care hospital (ACH) for lower extremity cellulitis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iron sucrose injection (1mg) for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the doctor will instead do a trial for the oral liquid iron supplement daily for tolerance.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found based on the records provided, this injections at issue in this case are not medically reasonable or necessary. There is a notation in the file that the enrollee will trial an oral liquid iron supplement daily for tolerance and clinical response prior to pursuing the intravenous iron infusions. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve iron sucrose injection (1mg) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on December 8, 2019.You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted did not support that a critical care visit of 30-74 minutes was performed on the billed date of service.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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the record. Specifically, the record does not include the time spent rendering the critical care service, therefore the code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on December 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for non-Medicare covered eyewear purchased on January 13, 2020.
You asked the Plan to pay for the eyewear. You say that you would not have purchased the non-Medicare covered eyewear if you had known that there would not be reimbursement from the health plan. The Plan denied your request. The Plan says you only have coverage for Medicare-covered eyewear. The plan states you were misinformed that you would be reimbursed $250. The plan reimbursed you due to the incorrect information given.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.
At this time, the plan has reimbursed you for $219, reflecting the charges for the existing receipt. The plan cannot issue payment for any additional amount based on the existing receipt on file as each line item has been reimbursed in full. Therefore, we decided that the Plan does not have to pay for non-Medicare covered eyewear purchased on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring
coded 95940 provided on December 17, 2019.
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. 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 95940 is continuous intraoperative neurophysiology
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List
separately in addition to code for primary procedure).
We find that CPT code 95940 is not supported in the medical record. Specifically, the documentation does not
contain sufficient detail to support Continuous intraoperative neurophysiology monitoring in the operating
room, one on one monitoring requiring personal attendance, each 15 minutes. Based on this information, we
decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring have not
been met. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative
neurophysiology monitoring coded 95940 provided on December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pulmonary embolization surgery provided on November 7, 2019.
You asked the Plan to waive the copayment for the pulmonary embolization surgery. You say that you should not be responsible for the surgery copayment. 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 $295 copayment. for surgery services at an in-network outpatient hospital. You have been asked to pay a $295 copayment for the pulmonary embolization surgery. The pulmonary embolization surgery falls within the "Outpatient surgery, including 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 copayment for the pulmonary embolization surgery provided on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control, a power seat elevation feature, privacy flap and electronic connection between wheelchair controller and two or more power seating system motors for the enrollee.
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that these items are not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The privacy flap 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. The rules say that if an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. An attendant control cannot be covered in addition to the enrollee-operated device control system already approved by the plan. The rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature. The rules also say that if two power seating functions/actuators/motors are provided, then one unit of E2311 (electronic connection between wheelchair controller and two or more power seating system motors) is allowed. The file indicates only one power seating function is being provided. Therefore, we decided that the Plan does not have to pre-approve an attendant control, a power seat elevation feature, privacy flap and electronic connection between wheelchair controller and two or more power seating system motors for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the elbow.
You asked the Plan to pre-approve the requested MRI. The Plan denied your request. The Plan says there was
no documentation of failure of non-operative treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested MRI. Our physician
reviewer found you are noted to have elbow pain with tenderness to the medial elbow. There is no evidence
that you have completed a course of conservative therapy, which was either ineffective or not tolerated. As
such, an MRI of the elbow is not shown to be currently medically necessary or reasonable.
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 requested MRI have not been met. Therefore, we decided that the Plan does
not have to pre-approve a magnetic resonance imaging (MRI) of the elbow.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the medical eye exam provided on January 29, 2020.

You asked the Plan to reduce the copayment for the medical eye exam. You say that you were told this was a routine visit. You say you paid a $20 copayment and are now being charged an additional $30 copayment. 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 diagnostic eye exam to treat diseases and conditions of the eye. 

You have been asked to pay a $50 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows a diagnosis of age-related cataracts which makes the eye exam medical in nature.

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 reduce the copayment for the medical eye exam provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional resin-based composites provided on January 20, 2020.
You asked the Plan to pay for the resin-based composites. You say that your dentist knew that you could only get two fillings per year. You also say that you did not tell them to provide this service. The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, restorations are limited to two procedures per calendar year. The record shows that you received four resin-based composites on January 20, 2020, two of which were covered by the Plan, and your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two additional resin-based composites provided on January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tub stool or bench (E0245).
You asked the Plan to pre-approve the tub stool or bench. You say that you were recently discharged from a skilled nursing facility. You live alone and needs assistance with showering and using the restroom The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 tub stool or bench (E0245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 Air fluidized bed.You asked the Plan to pre-approvea Group 3 Air fluidized bed (E0194). You say that a Group 3 Air fluidized bed is medically necessary.The Plan denied your request. The Plan says criteria is met for only a replacement Group 2 support surface. 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 a Group 3 Air fluidized bed (E0194). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has paraplegia and a stage 4 sacral pressure ulcer and a stage 4 right lower back pressure ulcer. The enrollee does not have a functional Group 2 support surface -the low air loss mattress that the enrollee has is not working properly. The enrollee is seeing a wound specialist and the provided medical records were reviewed. At issue in this case is the medical necessity of a Group 3 air fluidized bed (E0194).  Based on the medical records provided and the Local Coverage Determination (LCD): Pressure Reducing Support Surfaces -Group 3 (L33692) criteria, the enrollee does not meet the requirement for a Group 3 Air fluidized bed (E0194). The enrollee has not failed a properly working Group 2 support surface. The Plan has indicated that they are taking steps to providethe enrollee with a properly functioning Group 2 support surface.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 Group 3 Air fluidized bed (E0194) have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 3 Air fluidized bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for lymphedema and that they should be covered. The Plan denied your request. The Plan says the compression stockings are noncovered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health treatment.You asked the Plan to pre-approveinpatient mental health treatment. You say that the services are necessary.The Plandenied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked ourphysician 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 inpatient mental health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 28, 2020 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health treatment have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health treatment.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from February 4, 2020 to February 6, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you would like your hospital stay to be reconsidered as an inpatient stay. 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 $90 copayment for emergency services at an in-network emergency room. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were seen in the emergency room and admitted for observation.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided from February 4, 2020 to February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A5630.
You asked the Plan to pre-approve the compression stockings. You say that the stockings prevent your legs from swelling. The Plan denied your request. The Plan says the gradient compression stockings have been denied because they are not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A5630 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 A5630.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alveoloplasty, not in conjunction with extractions, (D7321) for the upper left and upper right quadrants, and the removal of the torus mandibularis (D7473).
You asked the Plan to pre-approve the dental services. You say that you got your teeth pulled at the end of January. You also say that you need to have the oral surgery so that you can get dentures. The Plan denied your request. The Plan says alveoloplasties and removal of the torus mandibularis are not listed as covered services.
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 alveoloplasties and removal of the torus mandibularis are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty, not in conjunction with extractions, (D7321) for the upper left and upper right quadrants, and the removal of the torus mandibularis (D7473).