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

We decided that the Plan does not have to pay for the exercise equipment (A9300) purchased March 17, 2021.
You asked the Plan to pay for the exercise equipment. You say that you were told by a Plan representative that you would be reimbursed if purchased by March 31, 2021, and the new benefit brochure also indicated this would be covered up to March 31, 2021. The Plan denied your request. The Plan says the temporary Coronavirus benefit ended on December 31, 2020. Your purchase was made after December 31, 2020; therefore, you do not meet the criteria for reimbursement.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when purchased between October 1, 2020, to December 31, 2020.
The Plan's rules for coverage of gym benefits have not been met because per the temporary enhanced benefits due to Coronavirus, you can use your $150 wellness allowance towards the purchase of exercise equipment that you can use at home for purchases made during the effective period of October 1, 2020, to December 31, 2020. You purchased your exercise equipment after December 31, 2020; therefore, this is not eligible for reimbursement. Therefore, we decided that the Plan does not have to pay for the exercise equipment (A9300) purchased March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric adjustable bed (E0303).

You asked the Plan to pre-approve a semi-electric adjustable bed. You say that you had ordered a hospital bed but it did not fit in the room, so you would like this adjustable bed. The Plan denied your request. The Plan says Medicare does not cover commercially available, non-hospital grade adjustable beds.

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 semi-electric adjustable bed (E0303).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the ribs; unilateral (71101) rendered by the out-of-network (OON) provider on February 16, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the ribs; unilateral (71101) rendered by the out-of-network (OON) provider on February 16, 2021.
Appeal type: Surgery
Decision: Unfavorable


We decided that the Plan does not have to pay for surgical preparation (15004) and an autograft (15120) provided on January 14, 2021.

You asked the Plan to pay for surgical preparation and an autograft. You say that these codes are supported. The Plan denied your request. The Plan says these codes are 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 15004 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children. The definition of 15120 is split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050).

We find that CPT codes 15004 and 15120 are not supported in the medical record. Specifically, the submitted medical records only document an evaluation and do not include the billed service. Based on this information, we decided that Medicare rules for coverage of surgical preparation and an autograft have not been met. Therefore, we decided that the Plan does not have to pay for surgical preparation (15004) and an autograft (15120) provided on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current 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 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.
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 long term acute care hospital (LTACH) services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on April 16, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the transport was medically necessary. The Plan denied your request. The Plan says non-emergency transport back to residence in long-term care; not bed confined; could have been transported via other means.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found that the documentation does not support that other means of transport were contraindicated such as a stretcher or wheelchair van. The documentation does not support that the enrollee required expertise or special equipment on the trip home via ambulance as she was stable. Therefore, this request for ambulance services will be considered not medically necessary as the documentation does not support this form of transportation on that date. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on April 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from July 29, 2020, to August 15, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not agree with this amount and never knew you would have to pay this much. You say that you are on a fixed income. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you hit your out-of-pocket maximum during this hospital stay, so you are only responsible for $1399.37 for these inpatient hospital services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment per day for days 1-8 and a $0 copayment per day for additional days for inpatient hospital care.
Records show that you were in the hospital for 17 days. You have been asked to pay a $200 copayment per day for the first 8 days the inpatient hospital services (for a total of $1600.) However, since you hit your out-of-pocket maximum during this hospitalization, you are only being charged the remaining amount of $1399.37. 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 inpatient hospital services you received from July 29, 2020, to August 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dementia, diabetes, Parkinson's disease, high blood pressure, depression, and a urinary tract infection. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a modified independent to supervision level with functional mobility including gait to 500 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion services (22633, 22634, 22840, 20930, 20936, and 61783).

You asked the Plan to pre-approve spinal fusion services. You say that the requested spinal fusion services with codes 22633, 22634, 22840, 20930, 20936, and 61783 is medically necessary. The Plan denied your request. The Plan says the requested spinal fusion services with codes 22633, 22634, 22840, 20930, 20936, and 61783 is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve spinal fusion services. Our reviewer says that the requested spinal fusion services with codes 22633, 22634, 22840, 20930, 20936, and 61783 is not medically necessary. Our physician reviewer found criteria for fusion not met.

There is no documentation of spinal instability or deformity. Fusion in 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 spinal fusion services have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion services (22633, 22634, 22840, 20930, 20936, and 61783).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no recommendation in the records for this device from the providers in direct care of the enrollee.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a stroke in the distant past, with resulting significant weakness in the left upper extremity. The proposed treatment with a powered upper extremity range of motion assist device has not been proven to be safe or effective for the treatment of the enrollee's condition.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Revo system adjustable socket (L5999).

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this socket does not have U.S. Food and Drug Administration (FDA) approval.

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 item. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Revo system is not FDA-approved, the efficacy and safety of the system has not been proven therefore is 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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve a Revo system adjustable socket (L5999).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 18, 2020 by a non-network provider.
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 rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided 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 for the laboratory services provided on March 18, 2020 by a non-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive medical eye exam you had with an ophthalmologist on December 21, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that you went in for a routine exam but were unaware that the services you received were not a routine exam. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for Medicare-covered vision care.
Records show on this date of service you had a medical eye exam. The medical records indicate that you were evaluated for retinal detachment, cataract, and macular degeneration. In addition to this medical eye exam, you also had fundus photography. These records show that this was clearly not a routine eye exam for which no copayment applies. You have been asked to pay a $35 copayment for the medical eye exam you had. 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 comprehensive medical eye exam you had with an ophthalmologist on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the nail debridement procedures you had from September 3, 2020 to March 4, 2021, at an outpatient hospital facility and the services you had with a podiatrist on March 4, 2021.

You asked the Plan to waive the copayments for the nail debridement procedures and the podiatry services. You say that you should not have to pay a facility fee for routine foot care. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the nail debridement procedures, the allowed amounts for this service is less than your copayment obligation, so you are responsible for the full allowed amounts.

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 $275 copayment for services in an outpatient hospital facility and a $25 copayment for services with a podiatrist.

Records show that you received had nail debridement procedures in an outpatient hospital clinic. You have been asked to pay a $275 copayment for each of these services. Because these services occurred in an outpatient hospital facility, you were appropriately charged a facility fee for each date of service. In addition, you were charged a $25 copayment for the podiatry services you had on March 4, 2021. Your Evidence of Coverage clearly states that you pay a $25 copayment for services with a podiatrist. 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 copayments for the nail debridement procedures you had from September 3, 2020, to March 4, 2021, at an outpatient hospital facility and the services you had with a podiatrist on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that the enrollee has fallen multiple times and it is unsafe to stand in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning provided on October 25, 2020.

You asked the Plan to pay for advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (99497). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation received did not support the service.

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 code 99497 is not supported in the medical record. Specifically, there is no documentation of advance care planning in the medical notes. Based on this information, we decided that Medicare rules for coverage of advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (99497) have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning provided on October 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand longer than a couple of minutes without pain and you have balance problems too. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.