Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) of the neck (70491).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says that the CT scan is not medically necessary at this time.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that coverage criteria has been met. Our physician reviewer found the enrollee has significant morbidity related to symptoms in his neck. This test is indicated as all other avenues of diagnosis have been utilized and a negative test would yield useful information for future treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to pre-approve Computed Tomography (CT) of the neck (70491).
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: Partially Favorable

We decided that the Plan has to reduce the amount due for the problem focused limited oral evaluation, bitewings, prophylaxis, and first intraoral periapical x-ray.
You asked the Plan to reduce the amount due for the problem focused limited oral evaluation, bitewings, prophylaxis, and first intraoral periapical x-ray. You say that during the 2019 benefit year the Plan has not paid for anything. The Plan says that that problem focused limited oral evaluation is not a covered benefit. The Plan also says that you were charged correctly for the bitewings, prophylaxis, and first intraoral periapical x-ray because they were rendered by an out-of-network provider.
We decided that the Plan has to reduce, but does not have to fully waive, the amount due for the problem focused limited oral evaluation, bitewings, prophylaxis, and first intraoral periapical x-ray.
The EOC clearly says that balance billing is not allowed. It says you can only be charged the cost sharing amounts listed in the EOC. It also says that non-covered services with out of network providers will be your full responsibility. The total amount of your responsibility is $75 ($39 in copayments + $36 of non-covered services = $75). Please refer to the chart below for more details.
Date of Service
Service Provided
Billed Amount
Allowed Amount
Plan Paid
Copayment
Non-covered enrollee responsibility
2/25/19
Bitewings (D0274)
$35
$35
$10
$25
N/A
2/25/19
Prophylaxis (D1110)
$60
$57
$57
$0
N/A
2/25/19
Periodic oral exam (D0120)
$29
$29
$29
$0
N/A
7/8/19
Problem focused oral exam (D0140)
$36
$0
$0
N/A
$36.00
7/8/19
Intraoral x-ray (D0220)
$15
$14
$0
$14 (less than the usual $25 copay)
N/A
TOTALS:
$39
$36
Therefore, we decided that the Plan has to reduce, but does not have to fully waive, the amount due for the problem focused limited oral evaluation, bitewings, prophylaxis, and first intraoral periapical x-ray.
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 stair lift.
You asked the Plan to pre-approve a stair lift. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a stair lift is not covered by Medicare or the Plan.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the semi-electric hospital bed provided on September 12, 2019, by an out of network provider.
You asked the Plan to pay for the semi-electric hospital. You say that you were not aware that the supplier was out-of-network. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network supplier.
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 at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the semi-electric hospital bed provided on September 12, 2019, by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide an automatic grasp feature, addition to upper limb electric prosthetic terminal device separately from the facility.
You asked the Plan to provide Automatic grasp feature (L6881) separately from the approved electric hand (L6880). You say that the enrollee needs the automatic grasp feature. The Plan denied your request. The Plan says all grasp patterns are included in the approved electric hand.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code Automatic grasp feature L6881 has a bundled relationship with code L6880 and cannot be paid if billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to provide an automatic grasp feature, addition to upper limb electric prosthetic terminal device separately from the facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and the cervical collar provided on October 29, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650), or the cervical collar (L0180). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician.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 in this case. The Delivery Ticket does not have the tracking numberon it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis and the cervical collar provided on October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for the continuous glucose monitor supply allowance purchased from the provider on August 30, 2019.You asked the Plan to reimburse you for the supply allowance. You say that the Plan should reimburse you for the approved supplies.The Plan denied your request. The Plan says that your claim was billed incorrectly by the provider.We find that the Plan has not provided a valid denial. The provider did not bill the Plan and you would not be expected to bill the supplies correctly.Based on this information, we decided that Medicare rules for coverage of the supply allowance have been met.Therefore, we decided that the Plan has to reimburse you for the continuous glucose monitor supply allowance purchased from the provider on August 30, 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/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 waive the copayment forvision exam and refraction services (92015) provided May 22, 2019.You asked the Plan to waive the copayment forthe vision services. You say that the plan paid a portion of the eye care visit. Please send the correct amount.The Plan denied your request. The Plan says the claim was processed and paid correctly per the benefits.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 any amount over $40 for routine eye examincluding refraction. for Vision care. You have been asked to pay $230. The plan contract says you must pay any amount over $40 for routine eye exam including refraction. The vision services fall within the Vision 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 forvision exam and refraction services (92015) provided May 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on October 17, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you had a positive Cologuard test so your doctor ordered the colonoscopy. You say the colonoscopy came back normal and you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $500 copayment for each visit to an outpatient hospital facility for Medicare-covered services. You have been asked to pay a $500 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the positive Cologuard test makes the colonoscopy diagnostic in nature.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe colonoscopy provided on October 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient status for pre-colonoscopy bowel prep.
You asked the Plan to pre-approve the inpatient status. You say that the member has had two failed colonoscopies in the past due to failed bowel prep. The Plan denied your request. The Plan says the records show that the member is 56 without documentation of severe heart, lung or kidney conditions.
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 inpatient status. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available records do not support that the procedure is emergent, pre-operative for a serious medical condition or that the member is at unusually high risk due to age or disease severity. 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 inpatient status have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient status for pre-colonoscopy bowel prep.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that your current inserts are old, decomposing and no longer doing the job.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management service (99354) provided on May 28, 2019.
You asked the Plan to pay for the prolonged evaluation and management service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include the time spent rendering the prolonged evaluation and management service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99354 is prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service).
We find that CPT code 99354 is not supported in the record. Specifically, the record does not include the amount of time spent providing the prolonged evaluation and management service. Based on this information, we decided that Medicare rules for coverage of the prolonged evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management service (99354) provided on May 28, 2019.
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 like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record shows that the member does not need to be seen by a rehabilitation doctor three timesa week or a need for an intensive team approach for care.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 member's nursing, medical and rehabilitation needs do not require an intensive therapy program for IRF admission. The member is functioning at a high level and does not need the intensity of therapies in and 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: 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 the records provided support the need for IRF care.The Plan denied your request. The Plan says the records do not show that the enrollee has complex therapy needs and a need to be seen by a rehab doctor at least three times weekly. The Plan says that the enrollee does not need an interdisciplinary approach with an intensive team for her care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medicallyreasonable 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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee has improved pain control and no significant post-operative complications. The enrollee may benefit from and participate in additional physical therapy and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on August 14, 2019.You asked the Plan to waive the copayment forthe ambulance services. You say that you were transported byEmergency Squad.The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $250 for these services. 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.Wood-Ridge FD Emergency Squad is a volunteer organization and did not submit a claim to the Plan. followed behind to provide advanced life support if needed. According to Medicare rules is allowed to bill for the services because they are contracted.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance services provided by on August 14, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Myocardial imaging, positron emission tomography (PET), perfusion study (78431).
You asked the Plan to pre-approve a Myocardial imaging, positron emission tomography (PET), perfusion study (78431). You say that the requested Myocardial imaging, positron emission tomography (PET), perfusion study (78431) is medically necessary. The Plan denied your request. The Plan says the requested 78431 is inclusive in the approved Myocardial imaging, PET (78433).
The Plan must follow Medicare rules. Medicare payment rules say procedure codes that are incorrectly reported with other procedure codes as a result of the misuse of the column two code with the column one code are not payable as there are limited circumstances when the column two code may be reported on the same date of service as the column one code. In this case, the plan has approved CPT code 78433. You also requested CPT code 78431, which is a column two code when reported with CPT code 78433 and cannot be approved based on Medicare coding guidelines as the plan approved procedure code 78433. CPT code 78433 is a comprehensive code and inclusive of CPT code 78431. Therefore, we decided that the Plan does not have to pre-approve a Myocardial imaging, positron emission tomography (PET), perfusion study (78431).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.You asked the Planto pre-approve the SNF admission. You say that the member has daily wound care, nursing and therapy needs. The Plan denied your request. The Plan says the member does not require skilled therapists to provide his daily hands-on care for mobility or activities of daily living.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 pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in an 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) and anti-reflective coating
(V2750) provided September 18, 2019.
You asked the Plan to pay for the vision services. You say that you purchased post cataract surgery eyewear
and paid the full amount and feel that you should receive full reimbursement. The Plan denied your request.
The Plan says these services are not covered benefits.
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 covers these services when covered eyeglasses after cataract surgery includes standard
frames and lenses. Any upgrades are not covered including, but not limited to deluxe frames, tinting,
progressive lenses and anti-reflective coating..
We looked at the file and the Plan's rules. the Plan's EOC specifically indicates these add on services are not
covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the vision
services have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses
(V2781) and anti-reflective coating (V2750) provided September 18, 2019.