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

We decided that the Plan does not have to pay for laboratory services (81328, 82175, 82300, 81226,81227, 81231, 81240, 81241, 81291, 81230, 82728, 82977, 83036, 83655, 83825, 82306, 82495, 81225) provided on July 9, 2020.

You asked the Plan to pay for laboratory services. You say that these services should be covered. The Plan denied your request. The Plan says these were screening services.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The testing at issue in this appeal was billed with screening diagnosis codes and were requested for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory services (81328, 82175, 82300, 81226,81227, 81231, 81240, 81241, 81291, 81230, 82728, 82977, 83036, 83655, 83825, 82306, 82495, 81225) provided on July 9, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tangential biopsy of the skin; single lesion (11102) provided January 14, 2021 to January 21, 2021.
You asked the Plan to pay for the procedure. You say that you have sent appeals with all supporting documentation/. You should be paid for services you provided. The Plan denied your request. The Plan says this service is bundled with another service. No documentation was submitted to support th
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 the procedure has a bundled relationship with code 10060 and cannot be paid as 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 pay for tangential biopsy of the skin; single lesion (11102) provided January 14, 2021 to January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on February 16, 2021.
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 $20 copayment per specialist visit. You have been asked to pay a $20 copayment for the specialist office visit 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 office visit (99203) provided on
February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the hip x-ray provided on March 11, 2021.

You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says
the claim processed 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 $25
copay for diagnostics procedures and tests in a specialist office.

You have been asked to pay a $25 copay for the services provided. The services fall within the outpatient
diagnostic tests 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 copay for the hip x-ray provided on March
11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation in a comprehensive manner in a facility that can provide the level of rehabilitation that the patient requires. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.
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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar decompression and fusion. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 IRF admission and services.
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 member's nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation 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 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 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 rhabdomyolysis and a fall. The enrollee's medical problems are stable. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prograf for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee was not enrolled in Medicare part A at the time of the transplant.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prograf for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home ventilator, any type, used with non-invasive interface (E0466) provided February 17, 2021, to April 17, 2021.
You asked the Plan to waive the coinsurance for the home ventilator. You say that you received your first bill on May 4, 2021. The coinsurance amounts for the ventilator is too high and you cannot afford it. The Plan denied your request. The Plan says these claims were processed with the correct copayment applied per the Evidence of Coverage.
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 Medicare covered DME items.
You have been asked to pay $566.67 ($188.89 coinsurance x 3 months) for the home ventilator. The home ventilator falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for the home ventilator, any type, used with non-invasive interface (E0466) provided February 17, 2021, to April 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on March 31, 2021.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support 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 valid relevant medical records which support medical necessity for the supplies provided in this case. The documentation does not support evidence of an established relationship between the enrollee and the ordering physician. 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 the shoulder elbow wrist hand orthosis provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5225).
You asked the Plan to pay for an upper partial denture. You say that you lost your previous denture and need a new one. The Plan denied your request. The Plan says you are not yet eligible for a new upper partial denture.
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. The Plan covers an upper partial denture once every five plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that an upper partial denture was previously covered on November 16, 2020. Based on this information, we determined that the Plan's frequency limit for an upper partial denture has been exceeded. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine foot care you received on March 15, 2021. 
 
You asked the Plan to pay for the foot care. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
The records do not show that any of these conditions are present. The services you are asking the Plan to pay 
for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the foot care have not been met. Therefore, we decided that the Plan does not have to pay for the routine foot care you received on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 10, 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 claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prosthetic device (C9600) provided on February 18, 2021.
You asked the Plan to waive the coinsurance for the prosthetic device. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a prosthetic device on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 Prosthetic Devices and Related Supplies. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a prosthetic device on February 18, 2021. The allowed amount for code C9600 is $6848.76 multiplied by 20% is your cost share. Since you only had $996.53 remaining to meet the out-of-pocket maximum, you are only responsible for paying this amount. The prosthetic device falls within the Prosthetic Devices and Related 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 coinsurance for the prosthetic device (C9600) provided on February 18, 2021.
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 you wear orthotics for alleviating pain and having balance issues 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 anesthesia services (00770) provided on September 9, 2020.
You asked the Plan to pay for anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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 00770 is anesthesia for all procedures on major abdominal blood vessels. We find that CPT code 00770 is not supported in the medical record. Specifically, the submitted medical records do not include an anesthesia report or other detailed documentation of the anesthesia services performed. Without this information, this code cannot be verified.
Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been
met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00770) provided on
September 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram and tomosynthesis
provided on January 12, 2021.
You asked the Plan to waive the copayment for the mammogram and the tomosynthesis. You say that you
already paid a copayment for the mammogram. You say received a facility fee from the medical center. The
Plan denied your request. The Plan says you have been asked to pay 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 $50
copayment for all other Medicare-covered outpatient diagnostic tests.
You have been asked to pay a $50 copayment for the mammogram and the tomosynthesis. The mammogram
and the tomosynthesis fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. The record shows you were charged separately by the facility for the mammogram and
tomosynthesis.
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 mammogram and tomosynthesis provided on January
12, 2021.
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 as a result from surgery your left leg is shorter than your right leg. 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 waive the copayment for the physician services rendered on December 18, 2020.
You asked the Plan to waive the copayment for these services. You say that there is no copayment for the annual wellness visit. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care provider.
Review of the file shows that you received services from your PCP on December 18, 2020. The records show that you received services outside of the scope of an annual wellness exam to address skin boils. You have been asked to pay a $10 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with your PCP or other primary care provider benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physician services rendered on December 18, 2020.