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

We decided that the Plan does not have to pre-approve additional power options for a wheelchair (E2311,
E2313, E2377).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the he documentation does not reveal that you require other types of proportional input devices
(e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional
input devices (e.g., sip and puff, head array, etc.). You do not need to operate 3 or more powered seating
actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an
attendant control. The documentation stats that the power wheelchair will help you perform MRADLs on his
own including hygiene. The documentation supports that your function in the upper extremities would be
sufficient for the patient to control any power options through their own individual switches.
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 accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power options for a wheelchair (E2311, E2313, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 5, 2020. You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the requested items were medically necessary. The Plan denied your request. The Plan says this patient did not receive video or telephonic visit by the ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section. 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 knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for advanced imaging provided by a participating provider on December 14, 2020, to December 16, 2020.
You asked the Plan to waive the coinsurance for an injection and copayment for advanced imaging. You say that you are on a limited income and cannot afford this. The Plan denied your request. The Plan says the correct coinsurance and copayment have been applied.
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 20% coinsurance for Medicare Part B prescription drugs/in-network and a $125 copayment for outpatient diagnostic tests/in-network/advanced imaging services/outpatient hospital. You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $125 copayment for advanced imaging. The total allowed amount is $112. The amount you are being asked to pay for the injection is $22.40 ($121 x 20% = $22.40). The total amount you are being asked to pay is $306.80 ($125 + $125 + $22.40 = $306.80). An injection falls within the Medicare Part B prescription drugs/in-network benefit category and advanced imaging falls within the outpatient diagnostic tests/in-network/advanced imaging services/outpatient hospital 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 coinsurance for an injection and copayment for advanced imaging provided by a participating provider on December 14, 2020, to December 16, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0425, A0427) provided on October 21, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $300 copayment for the Medicare-covered one-way ambulance trip provided. 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 ambulance transportation service (A0425, A0427) provided on October 21, 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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for congestive heart failure. His medical problems are now stable and he has no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While he may benefit from further therapy, there is not a reasonable expectation that the enrollee 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.

You asked the Plan to pay for a pneumatic compression device. You say that this item was medically
necessary. The Plan denied your request. The Plan says a pneumatic compression device to prevent deep vein
thrombosis during and/or following surgery is not covered.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.

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, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on November 17, 2020.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on November 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
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 had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. 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 the services provided to the enrollee by an out-of-network
provider on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150), unspecified periodontal procedure (D4999 x 2), the gingival irrigation (D4921 x 2), the scaling and root planing (D4341 x 2), and oral hygiene instructions (D1330) provided on December 8, 2020.
You asked the Plan to pay the in network rate for the dental services. You say that you do not agree with the member responsibility of $948. You say that you were told by the provider that they were in network and the services would be covered. You say that you feel you were given misleading information. You also say that you should only be responsible for the in network amount of $147. The Plan denied your request. The Plan says there is no coverage for an unspecified periodontal procedure, gingival irrigation per quadrant, and oral hygiene instructions. The Plan says that the provider in this case is out of network. The Plan says that additional payment for the comprehensive oral exam, and scaling and root planing. The Plan says that there is a 50% coinsurance for covered dental services that you receive out of network. The Plan also says that you did not contact the plan prior to the date of service to verify benefits and provider eligibility.
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 and comprehensive oral evaluation and scaling and root planing are listed as covered, there is a 50% coinsurance when you receive this service out of network. The unspecified periodontal procedure, gingival irrigation per quadrant, and oral hygiene instructions are not among those covered under this benefit. Additionally, the record shows that there was no call to the Plan to verify benefits or the provider's eligibility. Therefore, we decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150), unspecified periodontal procedure (D4999 x 2),
the gingival irrigation (D4921 x 2), the scaling and root planing (D4341 x 2), and oral hygiene instructions (D1330) provided on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on September 30, 2020.
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered. We looked at the file and Medicare rules. The test at issue is not covered. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided September 14, 2020.
You asked the Plan to pay for shoulder elbow wrist hand orthosis. You say that the items provided were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.
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 pay for shoulder elbow wrist hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided September 14, 2020.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for the antigen therapy services. We decided that the Plan does not have to waive the cost share for the antigen therapy services.
You asked the Plan to waive the cost share for the antigen therapy services. You say that these services were not medically necessary or completed for your benefit. The Plan says that you have been asked to pay the correct cost-sharing amount.
We decided that the Plan has to reduce the cost share for the antigen therapy services.
The record shows you were charged for code 95165 which is a professional service for the supervision of preparation and provision of antigens for allergen immunotherapy. Therefore, we decided that the Plan has to reduce the cost share for the antigen therapy services.
The Plan says you must pay $270.45 for the antigen therapy services on each date of service. Based on the Plan contract, however, you cannot be asked to pay more than a $40 copayment on each date of service for the antigen therapy services. Therefore, we decided the Plan must reduce the cost share from a $270.45 coinsurance on each date of service to a $40 copayment for each date of service.
We also decided that the Plan does not have to waive the cost share for the antigen therapy services.
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 $40 copayment for the antigen therapy services. Therefore, we decided that the Plan does not have to waive the cost share for the antigen therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on December 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided to the enrollee by an out-of-network provider on December 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of Achilles tendon services coded 27654 provided
on October 16, 2020.
You asked the Plan to pay for the repair of Achilles tendon services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
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 27654 is repair, secondary, Achilles tendon, with or
without graft.
We find that CPT code 27654 is not supported in the medical record. Specifically, the documentation does not
support that a secondary repair of the Achilles tendon was performed. Based on this information, we decided
that Medicare rules for coverage of the repair of Achilles tendon services have not been met. Therefore, we
decided that the Plan does not have to pay for the repair of Achilles tendon services coded 27654 provided on
October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for the continuous glucose monitor (K0553) and the continuous glucose monitor (K0554) provided on September 22, 2020.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the documentation provided does not support the billed items in this case.
The Plan must follow Medicare rules. Medicare rules say that the patient's medical record must contain 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 or replacement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Specifically, the record does not contain sufficient information of the patient's medical condition, as there was no documentation provided by the ordering physician. Therefore, we decided that the Plan does not have to pay for the supply allowance for the continuous glucose monitor (K0553) and the continuous glucose monitor (K0554) provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until December 24, 2020. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the services provided on May 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided to the enrollee by an out-of-network provider on July 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on August 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. 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 the services provided to the enrollee by an out-of-network
provider on August 10, 2020.