Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit (99202) provided on July 15, 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 that the copayment has been applied correctly to the service provided.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, an incorrect Plan contract for the year 2021 was provided for review. Our organization contacted the Plan and requested the Evidence of Coverage (EOC) that pertains to the 2020 calendar year; however, it was not provided. Therefore, we decided that the Plan has to waive the copayment for the office visit (99202) provided on July 15, 2020.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) services.
You asked the Plan to pre-approve the requested PT services. You say that it is felt that additional therapy is needed to reach the enrollee's goals. The Plan denied your request. The Plan says the requested therapy is not likely to effect long-term improvement as the response to the extensive PT provided thus far has been inconsistent.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 requested PT services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 requested PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lab services (81404, 81407, 81408) provided December 20, 2020.
You asked the Plan to pre-approve the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. This is not a covered service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pre-approve lab services (81404, 81407, 81408) provided December 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), controller harness (E2313), and related electronic connection (E2311) for use with a power wheelchair.
You asked the Plan to pre-approve the expandable controller and related hardware. You say that it is felt that all requested components are necessary. The Plan denied your request. The Plan says there is no documented medical need for the expandable controller.
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 expandable controller and related hardware. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case.
Our physician reviewer found the documentation does not reveal that the patient requires 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). The patient does 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 patient's strength and function in the upper extremities with
the ability to feed himself indicates that the patient can 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 expandable controller and related hardware have not been met. Therefore,
we decided that the Plan does not have to pre-approve an expandable controller (E2377), controller harness
(E2313), and related electronic connection (E2311) for use with a power wheelchair
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404) provided February 1, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559). We looked at the file and Medicare rules. Cardiovascular assessment panels are non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404) provided February 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for care in a SNF. The Plan denied your request. The Plan says SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the
enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning.
There were no skilled nursing needs. As of July 29, 2021, the enrollee did not require any skilled nursing or
rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable
and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of
daily living (ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance
program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF
level of care as of July 29, 2021. She did not have any parental medications, complex wound care or nutrition
given via a feeding tube. The enrollee received skilled care and improved; however, her function had plateaued
by July 29, 2021, and she did not require any further inpatient skilled rehabilitation services. The enrollee's
function was at or near her prior level of function and she could be discharged to a lower level of care for
further services. As of July 29, 2021, the enrollee required custodial services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 5, 2021.
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 services 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 January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 24, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment because the doctor did not do anything. You say the doctors confirmed you could have the knee injection after receiving the coronavirus vaccination and set up another appointment. 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 $30 copayment for medical care or surgery services in a specialty physician's office.
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows that you did have an office visit even though the cortisone shots were not administered. 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 specialist office visit provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404, 81479) provided January 12, 2021.

You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease. 

We looked at the file and Medicare rules. The cardiovascular risk testing at issue is non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81479) provided January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99215) provided on
April 8, 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 $30 copayment for each Medicare-covered specialist visit. You have been asked to pay a $30 copayment for the Medicare-covered specialist 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 (99215) provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2020), lens tint (V2744) and progressive lenses (V2781) provided on April 21, 2021.
You asked the Plan to pay for eyeglasses, lens tint and progressive lenses. You say that you know you exceeded your maximum benefit, but you could not see out of the last eyeglasses you purchased. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.
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 contract says you receive one pair of standard lenses and frames every two years. We looked at the file and the Plan's rules. The records show that you purchased eyeglasses on June 25, 2020. The records also show that you have exhausted your allowance benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses, lens tint and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2020), lens tint (V2744) and progressive lenses (V2781) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on January 12, 2021.
You asked the Plan to waive the copayment for an office visit. You say that this was a follow up and you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayment has 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 $15 copayment for physician/practitioner services/PCP. You have been asked to pay a $15 copayment for an office visit. Follow up appointments are subject to copayments; therefore, the correct copayment has been applied. An office visit falls within the physician/practitioner services/PCP 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 office visit provided by a participating provider on January 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90837) rendered by the out-of-network (OON) provider on February 23, 2021 and March 9, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 psychotherapy (90837) rendered by the out-of-network (OON) provider on February 23, 2021 and March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel release.
You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right arm pain. The examination revealed right hand intrinsic atrophy and bruising throughout the right upper extremity, along with a positive Tinel sign at the elbow and wrist. There is no detailed documetnation of a trial and failure of recent reasonable and comprehensive less-invasive conservative care measures. Furthermore, the electrodiagnostic test does not show carpal tunnel syndrome in the right upper extremity. Detailed documentation is not evident regarding objective findings that support carpal tunnel syndrome. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for carpal tunnel release, right side is not medically reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve carpal tunnel release.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on April 13, 2021.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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. Specifically, the document submitted as proof of delivery cannot be matched to the supplies provided. 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 durable medical equipment provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the crown on tooth #2 received March 18, 2021. We decided that the Plan does not have to pay for the periodontal scaling and root planing received March 18, 2021.
You asked the Plan to pay for the dental services received March 18, 2021. You say that the requested services were necessary. The Plan says that criteria for coverage of the requested services
We decided that the Plan has to pay for the crown on tooth #2 received March 18, 2021.
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 crown on tooth #2. Our reviewer says that the documentation provided supports that the crown on tooth #2 appears to be defective with faulty margins. The criteria for coverage for a replacement crown for tooth #2 has been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown on tooth #2 have been met. Therefore, we decided that the Plan has to pay for the crown on tooth #2 received March 18, 2021.
We also decided that the Plan does not have to pay for the periodontal scaling and root planing March 18, 2021.
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 scaling and root planing Our reviewer says the documentation provided does not support the criteria for coverage for scaling and root planing of the maxillary and mandibular right quadrants.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing March 18, 2021.
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.