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

We decided that the Plan does not have to pre-approve an electro-acupuncture device.
You asked the Plan to pre-approve an electro-acupuncture device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The case record indicates that the requested electro-acupuncture device is for a procedure performed in a clinic setting. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve an electro-acupuncture device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit you had on December 3, 2020.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit you had on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87487, 87500, 87640, and
87653 provided on November 6, 2020.
You asked the Plan to pay for the laboratory 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 payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 87487, 87500, 87640, and 87653 are not supported in the medical record. Specifically,
the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the
specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a
laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates
that the specimen was obtained in an office setting place of service 11. Based on this information, we decided
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services coded 87487, 87500, 87640, and 87653 provided on
November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a Freestyle Libre device.
You asked the Plan to pre-approve Freestyle Libre. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for Freestyle Libre have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a Freestyle Libre device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the laboratory services are not supported in the medical record. Specifically, these services should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for laboratory services provided on February
18, 2021.

You asked the Plan to waive the co payment for laboratory services. You say that you received the services as
part of your annual wellness exam and you should not be responsible for the 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
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
co payment for laboratory services.

You received laboratory services on February 18, 2021. Laboratory services are not included in annual
wellness exams and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the $10
co payment.

You have been asked to pay a $10 co payment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and 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 co payment for laboratory services provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on December 15,
2020.
You asked the Plan to waive the copayment for vision care. You say that you should not owe a copayment for a
routine eye exam. 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 $0
copayment for glaucoma screenings and diabetic retinal exams and a $30 copayment for all other vision
services for vision care.
The record shows that you received vision care on December 15, 2020. The services rendered went beyond a
glaucoma screening and diabetic retinal exam. Therefore, you are responsible to pay the $30 copayment.
You have been asked to pay a $30 copayment for vision care. Vision care falls within the vision care benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for vision care provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 13, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that you would like to appeal this service.
The Plan denied your request. The Plan says periodontal maintenance is not a covered service.
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, periodontal maintenance is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal
maintenance provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
December 27, 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 by an out-of-network provider on
December 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional biopsy.
You asked the Plan to pre-approve an incisional biopsy. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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 pre-approve an incisional biopsy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).

You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The Plan denied your request. The Plan says that a power seat elevation feature is non-covered because it is not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health skilled care. You say that without regular treatment you will
die. The Plan denied your request. The Plan says the denial of authorization for these services is correct,
because you no longer require skilled care and are not homebound.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health skilled care. Our reviewer
says that you do not meet the Medicare criteria for the requested home health care. Our physician reviewer
found you do not have documented skilled nursing or skilled therapy needs. As such, home health services are
not shown to be 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 home health skilled care have not been met. Therefore, we decided that the Plan
does not have to pre-approve home health skilled nursing 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.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. 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 was admitted for surgical treatment of a hip
fracture after a fall. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
can be provided in a different level of 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 4, 2021.
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 on January 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for postoperative care for cataract removal surgery (66984-55) provided from May 17, 2019, to June 7, 2019.
You asked the Plan to pay for postoperative care for cataract removal surgery. You say that these surgeries were co-managed. The Plan denied your request. The Plan says the claims for these surgeries were missing information.
The Plan must follow Medicare rules. Medicare rules say that where physicians agree on the transfer of care during the global period, modifier -55 is used for postoperative management. The date on which care was relinquished or assumed, as applicable, must be shown on the claim in the remarks field. We looked at the file and Medicare rules. The date on which care was assumed was not shown on the claim for the postoperative management at issue. Based on this information, we decided that Medicare rules for coverage of postoperative care for cataract removal surgery have not been met. Therefore, we decided that the Plan does not have to pay for postoperative care for cataract removal surgery (66984-55) provided from May 17, 2019, to June 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285, 93010) provided on
January 14, 2021.
You asked the Plan to pay for an emergency room visit. You say that the records support that this service was
medically necessary. The Plan denied your request. The Plan says this was billed with incorrect diagnosis
codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some
ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.
If the side is not identified in the medical record, assign the code for the unspecified side.
We find that this claim cannot be paid as billed. Specifically, the services at issue were billed with both the
ICD-10-CM code R10.10, upper abdominal pain, unspecified, and R10.11, right upper quadrant pain. It is not
appropriate to report both unspecified laterality and right laterality of the same symptom. Based on this
information, we decided that Medicare rules for coverage of an emergency room visit have not been met.
Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285, 93010) provided
on January 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve routine transportation. You say that you need to get to your appointments for the remainder of the year. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 42 one-way trips per year is not covered by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 42 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800).

You asked the Plan to pre-approve a standard power operated vehicle. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for a power operated vehicle have not been met.

The Plan follows Medicare rules. Medicare rules say that a POV will be covered if the criteria listed in the Medicare rules section have been met. 

The file does not document whether the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the requested POV. This means that Medicare rules for coverage of a POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) thorax (71250) computed
tomography (CT) abdomen and pelvis (74176).

You asked the Plan to pre-approve the CT scans. You say that please see attached for reconsideration. The Plan
denied your request. The Plan says based on the records provided the enrollee does not meet the criteria for
medical necessity.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the CT scans. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee is an 80-year-old male with unexpected weight loss, low appetite, lightheadedness,
anxiety, and memory impairment. Amiodarone use was suspected as possible culprit for the anorexia, but not
chosen to be adjusted. The provided records did not show first line testing for the above complaints including
blood work, standard cancer screenings. There was no evidence of an acute issue or criteria met for screening
with CT to justify this request. Therefore, the CT will be considered not medically necessary based on the
provided documentation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) thorax (71250) computed tomography (CT) abdomen and pelvis (74176).
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 patient does not require treatment by multiple therapies and there are no complex nursing or rehabilitation needs. 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. 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 pre-approve a powered pressure-reducing air mattress (E0277).
You asked the Plan to pre-approve the mattress. You say that you are getting sores on your back and the doctor recommended you get this air mattress. The Plan denied your request. The Plan says the records provided do not support that the enrollee meets the 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 the mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has a single stage 2 pressure ulcer on the buttock. The record does not indicate that the enrollee has failed a comprehensive ulcer treatment program. The elements of the coverage rule are not satisfied. 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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).