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

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.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 preapprove a pneumatic compression device (E0652)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laryngoscopies provided from October 23, 2019 to November 20, 2019.You asked the Plan to waive the copayments for the laryngoscopies.You say that you are being charged by both the practitioner and the hospital for same services. You are appealing the cost share applied from the hospital. 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 $300 copayment for Medicare-coveredsurgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $300 copayment for the laryngoscopies.You have been asked to pay a $189.47 copayment for each of the laryngoscopies. The laryngoscopies fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the laryngoscopies provided from October 23, 2019 to November 20, 2019.Your complaint about fraudulent double billing is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for first hour of non-face-to-face services (99358) skilled nursing facility (SNF) services (99306) provided on May 27, 2019.
You asked the Plan to pay for the SNF services. You say that in consideration for the services rendered, your doctor is seeking reimbursement from your office. The Plan denied your request. The Plan says this claim was processed correctly per how the provider billed the services. 99358 is an unlisted code and the plan requested supporting records but none were provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99358, 99306 is not supported in the medical record. Specifically, the requested medical records was not provided to verify that coverage criteria has been met. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for first hour of non-face-to-face services (99358) skilled nursing facility (SNF) services (99306) provided on May 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe physician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe physician services. You say that the requested services are medically necessary.The Plan denied your request. The Plan says the requested services can be provided in-network with a tertiary facility.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The provider at issue in this case is not a network provider with the Plan. 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 physician services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the enrollee is not currently receiving any active treatment and/or medical management of her condition with the requested providers. Her course of care with the requested provider/entity was limited to her acute hospitalization. The enrollee's stroke was adequately addressed while inpatient. The ongoing management of her condition (stroke prevention) will largely be managed by the enrollee's PCP and cardiologist (more than neurology). In this case, an in-network tertiary stroke specialist is medically necessary. The enrollee can continue to be cared for by another provider who was not necessarily at the hospital at the time of her stroke(s). The management approach would essentially beunchanged regardless of the provider's hospital affiliation. The Plan has a network tertiary provider the enrollee can receive her care from.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 physician services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the physician services.Therefore, we decided that the Plan does not have to pre-approvethe physician services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 26, 2019. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the partial thyroid excision provided on
November 13, 2019.
You asked the Plan to waive the copayment for the partial thyroid excision. You say that the procedure was
canceled. You say that you shouldn't be responsible. The Plan denied your request. The Plan says the
copayment 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 $50
copayment for outpatient surgery.
You have been asked to pay a $50 copayment for the partial thyroid excision. The partial thyroid excision falls
within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. The records show that the procedure was canceled after anesthesia was
administered. 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 partial thyroid excision provided on
November 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99307) provided on May 28, 2019.You asked the Plan to pay forthe nursing facility care. You say that the services were medically necessary.The Plan denied your request. The Plan says services were not preauthorized or emergent.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-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 forthe nursing facility care (99307) provided on May 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045), transportation of portable x-ray equipment and personnel to home or nursing home (R0070), and set-up of portable x-ray equipment (Q0092) provided on October 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe chest x-ray, transportation of portable x-ray equipment and personnel, and set-up of portable x-ray equipment. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.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-approve the item/service at issue. We found no exceptionthat would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71045), transportation of portable x-ray equipment and personnel to home or nursing home (R0070), and set-up of portable x-ray equipment (Q0092) provided on October 11, 2019 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 special pump services rendered to enrollee on November 13, 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 the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay for the special pump services rendered to enrollee on November 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 hours a week for a home health aide.
You asked the Plan to pre-approve the aide. You say that this is medically necessary. The Plan denied your request. The Plan says there is missing documentation, and no physician notes.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 aide. Our reviewer says that the requested aide is not medically reasonable or necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, to establish/perform a maintenance program to maintain your condition and/or prevent deterioration of your condition. The documentation does not reveal home health services are part of a physician treatment plan with physician progress notes. There is no evidence of complex wound care, IV medications, enteral feedings or other skilled nursing needs. The records do not reveal evidence of skilled therapy services that are required to effectively provide treatment, care, and/or services in order to improve your condition, to establish/perform a maintenance program to maintain your condition and/or prevent deterioration of your condition. Without evidence of SN or skilled therapy the definition of home health aide services as per Section 50.2 has not been met and home health aide services are not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. 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 aide have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 hours a week for a home health aide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 12, 2019 to the enrollee by an out of network (OON) provider.
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 the services were rendered by an out-of-network provider without prior authorization.
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-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 12, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefunctional electrical stimulator (FES) (E0770).You asked the Plan to pre-approvefunctional electrical stimulator. You say that you feel that this and acupuncture is medically necessary as the enrollee has completed this with improvement of pain and function of his hemiplegic side.The Plan denied your request. The Plan says this device is not covered when not used to walk. Per Medicare NCD guidance, this is not reasonable and necessary to treat the enrollee's condition.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 functional electrical stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee has a spinal cord injury therefore this request is 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 functional electrical stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvefunctional electrical stimulator (FES) (E0770).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker with seat and brake attachments.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that the clinical information they received does not state that you have a mobility limitation that prevents you from accomplishing MRADLs.
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 these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not support that you have a mobility limitation that significantly impairs your ability to participate in one or more mobility-related activities of daily living (MRADL) in the home. The documentation does not reveal whether you can safely use the walker or whether it will resolve your functional mobility deficit. Our physician reviewer found that your condition does not meet Medicare criteria for these items. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a walker with seat and brake attachments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Life Alert system.You asked the Plan to pre-approvea Life Alert system. You say that this will help you feel safe and secure.The Plan denied your request. The Plan says that the requested item is not covered by Medicare.The Plan must follow Medicare rules. The rules say that telephone alert systems are excluded from coverage as these are emergency communications systems and do not serve a diagnostic or therapeutic purpose.Although this device may be appropriate, it is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea Life Alert system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the insertion of central venous catheter
provided on October 3, 2019.
You asked the Plan to waive the copayment for the insertion of central venous catheter. You say that the
provider botched the procedure and it had to be repeated. 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 $375
copayment for outpatient hospital services.
You have been asked to pay a $375 copayment for the insertion of central venous catheter. The insertion of
central venous catheter 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 insertion of central venous catheter provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the varicose vein services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the varicose vein services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the varicose vein services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora laparoscopy (4204) provided on April 2, 2019 through April 3, 2019.You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 44204 has a status indicator of C, meaning it is an inpatient only code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 44204 is not supported in the record. Specifically, CPT code 44204 has a status indicator of C indicating that this is an inpatient only code and has been billed on an outpatient type of bill.  Based on this information, we decided that Medicare rules for coverage of the laparoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a laparoscopy (4204) provided on April 2, 2019 through April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea commode chair.You asked the Plan to providea commode chair. You say that you will need a commode chair because you are having surgery and your toilet is very low.The Plan denied your request. The Plan says your restroom is near your bed.The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room.The file does not show that you are confined to a bed or room as defined by Medicare rules.Therefore, we decided that the Plan does not have to providea commode chair.