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

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and pressure mattress.

You asked the Plan to pre-approve these services. 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 a semi-electric hospital bed and pressure mattress are covered when specific criteria are met.

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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has chronic hypercapnic respiratory failure, mixed sleep apnea, gastroesophageal reflux disease, severe chronic obstructive pulmonary disease and morbid obesity. The records show that she requires position of the body in ways not feasible in an ordinary bed. She does not require frequent or immediate changes in body position or special attachments that cannot be fixed and used on an ordinary bed. The semi-electric hospital bed is therefore not reasonable or medically necessary.

There is no documentation in the records that the enrollee has the degree of immobility required by the Medicare criteria or a pressure ulcer to support the need for the pressure mattress. The pressure mattress is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and pressure mattress.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for therapeutic activities provided on June 18, 2020.
You asked the Plan to pay for the therapeutic activities. You say that the services are medically necessary. The
Plan denied your request. The Plan says that the records do not support the service billed.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
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 pay for the therapeutic activities. Our reviewer says
that the therapy was medically necessary. Our physician reviewer found based on the medical records provided
there is documentation that the requested therapy was generally accepted as specific and effective therapy for
the enrollee's condition. The enrollee was documented to be home bound with decreased strength and standing
balance. Therapeutic exercise was provided, and teaching was provided with regard to a home exercise
program and safe transfers at the time of the June 18, 2020 home health occupational therapy treatment visit.
There is no documentation that the unique skills of a professional therapist were required to safely and
effectively provide treatment, that the services could have been safely and effectively performed only by a
therapist or under the supervision of a therapist. There was documentation that the specialized skill, knowledge
and judgment of a qualified therapist was required to establish, design and/or deliver a program to maintain the
patient's current condition or to prevent or slow further deterioration.
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 therapeutic activities have been met. Therefore, we decided that the Plan has
to pay for therapeutic activities provided on June 18, 2020.
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/or send 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three additional intraoral periapical x-rays (D0230 x3) provided on November 10, 2020.
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you need help with this bill. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the three additional intraoral periapical x-rays (D0230 x3) provided on November 10, 2020.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was with sepsis secondary to an infected hip arthroplasty. The enrollee is improving and requires a single intravenous antibiotic and oral antibiotics. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220), and to pay more for the periodic oral evaluation (D0120), and prophylaxis (D1110) provided on January 14, 2021, and January 25, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray, or pay more for the periodic oral evaluation, and prophylaxis. The Plan denied your request. The Plan says the problem focused limited oral evaluation and first intraoral periapical x-ray are not covered benefits under your dental plan. The Plan also says that if you choose to see an OON dentist, you might be billed for any amount greater than what the Plan pays.
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 problem focused limited oral evaluation and first intraoral periapical x-ray are not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220), and to pay more for the periodic oral evaluation (D0120), and prophylaxis (D1110) provided on January 14, 2021, and January 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring rendered on July 14, 2020.

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 claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 continuous intraoperative neurophysiology monitoring rendered on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Botox.
You asked the Plan to pre-approve Botox. You say that it is recommended for the enrollee to discontinue Reglan therapy and Botox would be a good alternative. The Plan denied your request. The Plan says the denial of authorization for Botox is correct, because studies have not proven that this drug is helpful for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Botox. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Botox. Our physician reviewer found the requested use of Botox is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. Overall, the clinical value and effectiveness of Botox in the setting of gastroparesis has not been demonstrated in peer-reviewed literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Botox.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on March 3, 2021.
You asked the Plan to waive the copayment for lab services. You say that the labs had to be repeated due to
severe weather and you were told you would not owe an additional copayment. The Plan denied your request.
The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for lab services.
You have been asked to pay a $10 copayment for lab services. Lab services fall within the outpatient diagnostic
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for lab services provided on March 3, 2021.
We note your complaint that you were told that you would not owe an additional copayment for the repeated
lab services. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit
us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on February 1, 2021.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 billed incorrectly.The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component testresults and was not billed as one test under code 81479.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services (CPT code(s): 87500, 87563, 87801) provided to the enrollee on July 10, 2020.You asked the Plan to pay forthe laboratory services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 87500 (1 Unit) remains not supported. The place of service on the CMS-1500 formline 24B must reflect the location of the enrolleewhen the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicatesthat the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 10, 2020,and received by the lab on July 15, 2020; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.CPT code87801 (3 Units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrolleewhen the specimen was obtained. Thesubmitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 10, 2020,and received by the lab on July 15, 2020; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.CPTcode 87563 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient enrollee when the specimen was obtained.The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 10, 2020,and received by the lab on July 15, 2020; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.Therefore, we decided that the Plan does not have to pay forthe laboratory services(CPT code(s): 87500, 87563, 87801) provided to the enrollee on July 10, 2020
Appeal type: Other
Decision: Partially Favorable

We decided that the Plan has to reimburse you for any additional amount you paid in excess of your copayment.. We decided that the Plan does not have to reimburse you for the $100 copayment.
You asked the Plan to reimburse you for any additional amount you paid in excess of your copayment. You say that you would like reconsideration because you should be reimbursed for the entire or expected amount assessed. The Plan says that the maximum amount allowed for this service is $174.93; therefore the Plan is only responsible for the remaining $74.93.
We decided that the Plan has to hold you harmless for any additional amount you paid in excess of your copayment.
The Plan follows Medicare rules. Medicare rules say that when a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service. We looked at your request, the file and Medicare rules. The record indicates that these services were rendered by a plan provider. You must be held harmless and need not pay more than your contracted cost sharing amount. It is the Plan's obligation to ensure that you are made whole. They can do that by either paying you directly for the difference, or by directing the provider to do so. Therefore, we decided that the Plan has to hold you harmless for any additional amount you paid in excess of your copayment.
We also decided that the Plan does not have to reimburse you for the $100 copayment.
The Plan follows Medicare rules. Medicare rules say that a health 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 $100 copayment for outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers. You have been asked to pay a $100 copayment for an outpatient surgical procedure. The records show that the maximum allowed fee (MAF) for this procedure is $174.93. The records also show that the Plan is responsible for $74.93. The EOC confirms that $100 is the required copayment for this service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a tattoo micropigmentation outpatient surgical procedure (11920) provided on November 7, 2020.
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/or send 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hyperbaric oxygen treatment provided July 30, 2020.
You asked the Plan to waive the copayment for the hyperbaric oxygen treatment. You say that you were not aware the enrollee would be charged a copayment. The Plan denied your request. The Plan says the claim processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $175 copayment for outpatient hospital services. The enrollee has been asked to pay a $175 copayment for the hyperbaric oxygen treatment. the hyperbaric oxygen treatment falls within the outpatient hospital services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the hyperbaric oxygen treatment provided July 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora duplex scan provided on February 18, 2021.You asked the Plan to waive the copayment fora duplex scan. You say that you feel that the provider was a freestanding facility and not an outpatient hospital facility. You state that if you had known you wouldowe such a high copayment you would have found a more reasonable provider.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 $100 copayment for diagnostic procedures and tests provided at an outpatient hospital facility. The record shows that you received a duplex scan at an outpatient hospital facility on February 18, 2021. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for a duplex scan. A duplex scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora duplex scan provided on February 18, 2021.