Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 4, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you will be looking for a new provider because you are unhappy with the service you received and fill that the charges are too high. 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 $110 copayment for ultrasounds. 

You have been asked to pay the allowed amount of $52.25, which is less than the $110 copayment for an ultrasound. An ultrasound 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 for an ultrasound provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483 and 80307) provided on July 1, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim indicates that the laboratory specimen was obtained in a laboratory.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim indicates that the specimen was collected in a laboratory setting, but the record submitted indicates that the face-to-face service was not rendered in the laboratory setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483 and 80307) provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tubing (A4616 and A7037), face mask (A7030) and filter (A7038) provided on May 17, 2019.

You asked the Plan to pay for the supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation does not include a valid physician order.


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 physician order for the supplies provided in this case. 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 for tubing (A4616 and A7037), face mask (A7030) and filter (A7038) provided on May 17, 2019,
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for occlusal adjustment - limited (D9951) provided on October 14, 2020.

You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for occlusal adjustment - limited (D9951) provided on October 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services (R0070) provided on May 22, 2020.

You asked the Plan to pay for portable x-ray services. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS code.

The Plan must follow Medicare rules. Medicare rules say that Place of Service (POS) code 31 should be used with services for patients in a Part A covered skilled nursing facility stay and POS code 32 should be used with services for beneficiaries in a noncovered stay. 

We looked at the file and Medicare rules. This service was billed with POS code 31, but the record indicates this service was provided during a non-covered skilled nursing facility stay and requires POS code 32. Based on this information, we decided that Medicare rules for coverage of portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray services (R0070) provided on May 22, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for respiratory disorder panel provided on May 27, 2020.

You asked the Plan to pay for the respiratory panel. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says that this is not a covered benefit.

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. 

The enrollee was referred for the respiratory panel by a contract provider. The file does not show that the plan provided notice that the respiratory panel would not be covered. Under Medicare rules, this means the respiratory panel is considered approved by the plan. Therefore, we decided that the Plan has to pay for respiratory disorder panel provided on May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916-LT) and DME delivery (A9901) provided on August 4, 2020.

You asked the Plan to pay for wrist hand orthosis and delivery. You say that the item is medically necessary. The Plan denied your request. The Plan says the records lack in-person assessment information such as range of motion or strength tests and the member denies seeing or speaking with this physician.

The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been 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 pay for wrist hand orthosis and delivery. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the wrist/hand orthoses were medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the wrists.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wrist hand orthosis and delivery have not been met. Specifically, there is no indication the item is medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for wrist hand orthosis (L3916-LT) and DME delivery (A9901) provided on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre sensor.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the prior authorization criteria were not met.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that you are taking insulin for treatment of diabetes. There is no documentation that the treatment requires frequent adjustment on the basis of testing results. 

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 a Freestyle Libre sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment (D1999) provided on July
7, 2020.

You asked the Plan to pay for the personal protective equipment (PPE). You say that the provider in this case
was listed as in network with the Dental Plan. You say that you did everything possible to make sure that the
provider was in network. You say that the services you received should be covered. The Plan denied your
request. The Plan says personal protective equipment is not listed as a covered service.

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
personal protective equipment (D1999) provided on July 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
March 9, 2020, to June 7, 2020.

You asked the Plan to pay for the SNF services. You say that the enrollee was given physical therapy,
occupational therapy, and speech therapy in accordance with the doctor's order. You also say that the enrollee
required skilled nursing care that could only be provided under the supervision of skilled licensed professionals
and not in a facility that provided custodial care. The Plan denied your request. The Plan says the enrollee did
not require any daily skilled nursing or rehabilitative services. The Plan also says that assistance with personal
cares or taking medications is considered custodial care rather than skilled care under Original Medicare
standards and is not eligible for coverage.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 pay for the SNF services. Our reviewer says that the
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF setting.

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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided from March 9, 2020, to June 7, 2020.
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 the home health care agency feels you need a higher level of care. The Plan denied your request. The Plan says you can receive care in another setting.

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. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that the enrollee has been on Prolia therapy since March 22, 2019. You say that due to the enrollee's age and diagnosis of osteoarthritis involving multiple joints, she is at risk of falls. You say that the diagnosis of osteoporosis the enrollee is at risk of fractures. You also say that it is highly recommended that the enrollee continue Prolia therapy. The Plan denied your request. The Plan says the request for Prolia to be dispensed by a pharmacy is not covered under Part B Medicare.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to a facility for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. 

The Plan says that the enrollee can safely receive the services needed 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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart
failure. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission.
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the medical record documents a need for physical and occupational therapy, it does not
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the short leg splint application rendered on July 5, 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 procedure code 29515 is not separately payable.

The Plan must follow Medicare rules. The rules say that, for edits with a modifier indicator of 0, the Column 2 code cannot be paid regardless of whether a modifier is used. 

The provider submitted a claim for procedure codes 29515 and 64450. Code 29515 is a column II code with a modifier indicator of 0 when billed with column I code 64450. Code 29515 cannot be separately paid. Therefore, we decided that the Plan does not have to pay for the short leg splint application rendered on July 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 23, 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 of area 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 the Plan. 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 on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic test strips (A4253), calibrator solution (A4256), and lancets (A4259) provided on June 3, 2020.

You asked the Plan to pay for diabetic test strips, calibrator solution, and lancets. You say that these items were medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.

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 physician order. Specifically, the submitted physician order is dated July 8, 2020, which is after the date of service at issue in this case. The submitted physician order does not apply to the items at issue in this case. 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 for diabetic test strips (A4253), calibrator solution (A4256), and lancets (A4259) provided on June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the PET scan provided on November 3, 2020.

You asked the Plan to reduce the coinsurance for the PET scan. You say that you would like a $275 copayment instead of 20% coinsurance for the PET scan. 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 20% coinsurance for each in-network Medicare-covered service. 

You have been asked to pay $943.66 which is 20% of the allowed amount for the PET scan. The allowed amount is $4,718.30. ($4,718.30 x 20% = $943.66). The PET 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 reduce the coinsurance for the PET scan provided on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair transit kit.

You asked the Plan to pre-approve a transit kit. The Plan denied your request. The Plan says the kit is a non-medical feature that is intended for use outside the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve power wheelchair transit kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair with custom seating.

You asked the Plan to pre-approve a wheelchair with custom seating. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

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 a wheelchair with custom seating is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a wheelchair with custom seating.