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 E1399.
You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 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 E1399.
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 you would benefit from these services. The Plan
denied your request. The Plan says that you can safely continue receiving the services you need in other
settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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. You
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be
able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care
needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet
Medicare criteria for IRF care.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe treatment of a thigh fracture (27235) provided on August 12, 2020.You asked the Plan to pay forthe treatment of a thigh fracture. You say that the presence of this provider was vital to ensure the safety of the member.The Plan denied your request. The Plan says CPT code 27235 has an assistant surgery indicator of 1 which does not allow assistant surgeon payment.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 27235. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the treatment of a thigh fracture have not been met.Therefore, we decided that the Plan does not have to pay forthe treatment of a thigh fracture (27235) provided on August 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the claim was billed with an invalid type of bill for a non-participating Home Health provider. The Plan states a corrected claim would be accepted if submitted. 

The Plan must follow Medicare rules. Medicare rules state that providers must use appropriate codes. In this case the claim submitted has an incorrect type of bill code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe GeneSight Assay provided on June 10, 2020.You asked the Plan to pay forthe GeneSight Assay. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that GeneSight testing is only covered when ordered by a licensed psychiatrist or neuropsychiatrist.We looked at the file and Medicare rules. Review of the file shows that this test was ordered by a nurse practitioner who works with a doctor that is a family medicine physician. This test was not ordered by a licensed psychiatrist or neuropsychiatrist. Based on this information, we decided that Medicare rules for coverage of the GeneSight Assay have not been met.Therefore, we decided that the Plan does not have to pay forthe GeneSight Assay provided on June 10, 2020
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe lab testing services provided on October 21, 2019.You asked the Plan to pay fortheservices provided. You say that lab work is covered per your plan.The Plan denied your request. The Plan says that the services are not payable by Medicare.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the services provided by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe lab testing services providedon October 21, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hip Arthroscopy - CPT code(s) 29916, 29914, 29862.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are not necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found Hip Scope surgery not needed at this time. There is no documentation of a recent trial and
failure of physical therapy (PT) for hip pain.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Hip Arthroscopy - CPT code(s) 29916, 29914, 29862.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided from June 26, 2020, to June 27, 2020.
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that this claim should be covered by the Plan. The Plan denied your request. The Plan says payment for these drugs must be submitted to your Medicare Part D carrier.
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 pay for self-administered drugs provided from June 26, 2020, to June 27, 2020. Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 11, 2020 with a right cerebellar hemorrhage and hypertension. The physicaltherapy note dated December 14, 2020 states she needs modified assist to sit up, stand up, and maximum assist to stand. She does not require the intensity of services in an IRF. Specifically, she does not require 15 hours per week of rehabilitative services with regular physician evaluation. The IRF services are not medically 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital care (99223) provided on April 28, 2019.You asked the Plan to pay forhospital care. You say that the claim was filed timely with the Plan.The Plan denied your request. The Plan says rules for payment have not been met.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for hospital care was not filed until May 25, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forhospital care (99223) provided on April 28, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit provided
on August 21, 2020.
You asked the Plan to waive the copayment for the emergency department visit. You say that you were sent to
the emergency department after an ultrasound, but you were not treated. The Plan denied your request. The
Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110
copayment for Emergency Care.
You have been asked to pay a $110 copayment for the emergency department visit. the emergency department
visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the emergency department visit provided on August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass lenses (V2100) and an unspecified vision item or service (V2799) received on August 18, 2020.
You asked the Plan to pay for eyeglass lenses and an unspecified vision item or service. You say that you were unaware that you had a two-year restriction to get glasses under your Plan. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides a $200 vision allowance every two years for routine eyewear. We looked at the file and the Plan's rules. The case record indicates that you previously received routine eyewear on March 8, 2019 and are therefore ineligible for further benefits until March 8, 2021.
An unspecified vision item or service is not covered under the Plan's routine vision and eyewear benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglass lenses and an unspecified vision item or service have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass lenses (V2100) and an unspecified vision item or service (V2799) received on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forinfusion supplies (A4222, E0781) provided from July 9, 2019, to July 23, 2019.You asked the Plan to pay forinfusion supplies. You say that these items should be covered.The Plan denied your request. The Plan says these items are not separately payable.The Plan must follow Medicare rules. Medicare rules say that when medical and surgical are provided incident to a physician's service by a hospital outpatient department, the HCPCS codes for these items should not be reported because these items represent supplies.We looked at the file and Medicare rules. The items at issue are supplies that were provided incident to a physician's service by a hospital outpatient department.Based on this information, we decided that Medicare rules for coverage of infusion supplies have not been met.Therefore, we decided that the Plan does not have to pay forinfusion supplies (A4222, E0781) provided from July 9, 2019, to July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from May 20, 2020, through July 22, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out ofarea urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 requested provider in this case is not a network provider with thePlan. The Plan did not pre-approve the physician's services. 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 physician's services provided from May 20, 2020, throughJuly 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuous positive airway pressure (CPAP) device (CPT Code E0601).You asked the Plan to pre-approvethe CPAP device. You say that the device is necessary.The Plan denied your request. The Plan says there is no submitted documentation of clinical re-evaluation by treatingpractitioner to indicate symptom improvement with use of CPAP.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 CPAP device. Our physician reviewer found the criteria for continued coverage of CPAP are not met. You have OSA, and was started on CPAP in September 2020. Compliance data for November 4, 2020, through December 3, 2020, does not meet the minimum Medicare requirement of at least 70% of days with at least 4 hours of use. There has as yet been no follow-up visit to assess CPAP use and benefit. CPAP is considered not medically necessary, and the denial is upheld. 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 CPAP device have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuous positive airway pressure (CPAP) device (CPT Code E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on June 9, 2020.

You asked the Plan to pay for the pneumatic compression device. You say that you would like reconsideration because the equipment was ordered by the physician and medically necessary. The Plan denied your request. The Plan says payment for this service is included in the facility DRG payment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that the pneumatic compression device was used in a hospital. Payment for this service would have been included in the facility DRG payment. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ankle orthoses (L1971 and L3170) provided on May 15, 2020.You asked the Plan to pay forthe ankle orthoses. You say that you would like reconsideration because this equipment is medically necessary.The Plan denied your request. The Plan says documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided inthis case. Specifically, the record does not include an itemized shipping/delivery sheet to verify the supplies billed. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe ankle orthoses (L1971 and L3170) provided on May 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe risk assessment panel provided on April 28, 2020.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Per LCD L36523, the requested risk assessment panel is non-covered. 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 forthe risk assessment panel provided on April 28, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvediabetic testing supplies for high utilization.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.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 Plan states that the services are not medically necessary; however, there are no medical records received with the case file. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approvediabetic testing supplies for high utilization. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from March 25, 2019, to
April 1, 2019.
You asked the Plan to pay for inpatient care. You say that every effort is made to bill the claim in a timely
manner. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because this claim was not billed within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for inpatient care was not filed until September 18, 2020. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for inpatient hospital care provided from March 25, 2019, to April 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and related services provided on August 15, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit and related services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out of network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approvethe 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 forthe office visit and related services provided on August 15, 2020 by an out of network (OON) provider.