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

We decided that the Plan does not have to reimburse you for the durable medical equipment purchased from February 23, 2019 to March 22, 2019.You asked the Plan to reimburse you for the knee scooter, transfer bench, commode chair, walking boot, portable ramp, grabbing device and sales tax. You say that you were not aware medical equipment needed to be purchased from a Medicare certified supplier.The Plan denied your request. The Plan says provider is not a Medicare certified supplier and there are providers available to receive these items from.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by Amazon.com. This provider has opted out of the Medicare program. The file shows that Amazon.com entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to reimburse you for the durable medical equipment purchased from February 23, 2019 to March 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device.
You asked the Plan to pre-approve the requested item. You say that the machine prevents blood clots after surgery, and improves blood flow. The Plan denied your request. The Plan says items that are used for a preventive service or function are not covered.
The Plan must follow Medicare rules. Medicare rules say that items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. We looked at the file and Medicare rules. While an intermittent limb compression device may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, a harness, and an electrical
connection for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no medical need to control these power options through the joystick.
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 records do not indicate a need for such accessories. They will not serve to enhance the
performance of this power mobility device and/or improve the enrollee's ability to perform MRADL's. As they
are convenience items, they are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve an expandable controller, a harness, and an electrical connection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, first intraoral periapical x-ray, each additional intraoral periapical x-ray, and comprehensive oral evaluation provided on October 7, 2019.You asked the Plan to pay for the prophylaxis, intraoral periapical x-rays, and comprehensive oral evaluation. You say that you have Medicaid and do not understand why Medicare does not cover these basic services. You also say that you had not had your teeth cleaned in over a year.The Plan denied your request. The Plan says these services are not covered 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.Therefore, we decided that the Plan does not have to pay for the prophylaxis, first intraoral periapical x-ray, each additional intraoral periapical x-ray, and comprehensive oral evaluation provided on October 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device (22869).
You asked the Plan to pre-approve the Vertiflex device. You say that the device is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for treatment of the member's condition.
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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental and more research is needed to show safety and efficacy. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device (22869).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on October 7, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you followed the doctors instructions and ended up in the emergency room. You say that the Plan should cover the copayment. The Plan denied your request. The Plan says the copayment 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 $100 copayment for emergency care. You have been asked to pay a $100 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were treated in the emergency department. 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 ED visit provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99334, 99325) provided on April 5, 2019 to April 19, 2019 by out of network provider.You asked the Plan to pay fora domiciliary or rest home visit. You say that the member was in a nursing facility. The doctor was not responsible to get authorization. The Nursing Home is responsible to obtain prior authorization for their patients which should cover medical treatments by the provider.The Plan denied your request. The Plan says physician is outside of the member's network of providers and prior authorization was not obtained. The claim does not meet the urgent or emergent criteria based on the CPT codes or the diagnosis code submitted. There is also no documentation that this member was referred to this non-contracted provider by a contracted provider, and no indication that any attempt was made to obtain prior authorization for the rendered services.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/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora domiciliary or rest home visit (99334, 99325) provided on April 5, 2019 to April 19, 2019 by out of network provider.Please remember that you signed a Waiver of Liability in which you agreed not to bill enrollee for these services. This Waiver does not, however, deny your right to seek further appeal from an Administrative Law Judge
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on November 18, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be responsible for the copayment. You say the doctor only had your history, signs, and symptoms to make a diagnosis and you were prescribed physical therapy. 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 $45 copayment per specialist visit. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 forthe specialist office visit provided on November 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections (64490 and 64491).
You asked the Plan to pre-approve facet injections (64490 and 64491). You say that the requested facet injections are medically necessary. The Plan denied your request. The Plan says the requested facet injections do not meet criteria.
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 facet injections (64490 and 64491). Our reviewer says that the requested facet injections do not meet criteria. Our physician reviewer found this enrollee has chronic neck pain without radiation to his arms. The enrollee underwent diagnostic facet injections
and achieved 75% pain relief and improved range of motion. The request is for repeat diagnostic blocks. Medicare criteria requires documentation of 80% pain improvement which was not achieved here. Therefore, the request is considered not medically reasonable or necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet injections (64490 and 64491) have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections (64490 and 64491).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance for the part B injections you received from March 11, 2019, to July 31, 2019.You asked the Plan to waivethe cost share. You say that you cannot afford to pay for the services.The Plan denied your request. The Plan says you are responsible for the cost share.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-covered Part B drugs. Review of the file shows that you received Part B injections from March 11, 2019, to July 31, 2019. You have been asked to pay a 20% coinsurance for the services, totaling $1.46. The services fall within Part B drugs 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 waivethe coinsurance for the part B injections you received from March 11, 2019, to July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a security poll and bar.
You asked the Plan to pre-approve the security poll and bar. You say that you require the stander support pole to be able to get out of bed. The Plan denied your request. The Plan says a standard security pole is not used for a medical need and cannot be approved.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a security poll and bar.
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 October 15, 2019.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on October 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on September 18, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you disagree with the surgical charges. 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 $345 copayment outpatient surgical services provided in an outpatient hospital facility. You received an EGD on September 18, 2019. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $345 copayment. You have been asked to pay a $345 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seat attachment, walker (CPT Code E0156).
You asked the Plan to pre-approve walker seat attachment. You say that you have lower back pain and muscle contractions with pain that make it difficult to move. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve seat attachment, walker (CPT Code E0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says continued acute hospital stay can be offered, until the enrollee can discharge
to a lower level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in
general, LTACHs do not provide clinical services that are materially different than those of short term acute
care hospitals. In this case, ongoing care needs include respiratory support with ventilator management,
weaning, and nebulizer treatments, wound care, surveillance laboratory studies, and therapy services. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for severing adhesion of the eye (65870) provided on August 20,
2019.
You asked the Plan to pay for severing adhesion of the eye. 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 a detailed procedure note of severing adhesions of anterior segment of eye, incisional technique (with
or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae.
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 65870 is severing adhesions of anterior segment of eye,
incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except
goniosynechiae.
We asked our coder 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 severing adhesion of the eye. Our reviewer says that the
documentation is of insufficient quality and content to support that the billed procedure was performed. Our
reviewer found listing any procedure as having been performed is not the same as documenting performance of
the procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of severing adhesion of the eye have not been met. Therefore, we decided that the
Plan does not have to pay for severing adhesion of the eye (65870) provided on August 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana for the enrollee.
You asked the Plan to pre-approve Invokana. The Plan denied your request. The Plan says that this medication is not covered under Part B.
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 Invokana for the enrollee.
Benefits for Invokana 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 pay for the ABPM (CPT Code A4670) provided to the enrollee on September 3, 2019. 
 
You asked the Plan to pay for the ABPM. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ABPM have not been met. The ABPM is only covered for suspected white coat hypertension, and must be performed for at least 24 hours to meet coverage criteria. Suspected white coat hypertension is defined as 1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; 2. At least two documented blood pressure measurements taken outside the office which are <140/90mm Hg; and3. No evidence of endorgan damage. The ABPM is not covered for any other uses. Therefore, we decided that the Plan does not have to pay for the ABPM (CPT Code A4670) provided to the enrollee on September 3, 2019.