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

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).You asked the Plan to pre-approve the total electric hospital bed. You say that you are in extreme discomfort when using a regular bed.The Plan denied your request. The Plan says this is not a covered item.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed 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 a total electric hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0483) provided on October 2, 2018.
You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records indicate that definitive, utilizing drug identification methods with less than 22 drug classes were performed.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed . 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 the drug test. Our reviewer says that CPT code G0483 does not meet criteria for billing or reimbursement consideration. Our coder found the medical records provided do not contain documented definitive laboratory results for 22 or more drug classes, therefore this service cannot be validated. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not have to pay for a drug test (G0483) provided on October 2, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Services (99284) provided on August 28, 2019. You asked the Plan to pay for the Emergency Room Services. You say that the services at issue were two different encounters.The Plan denied your request. The Plan says the second claim represents a continuum of care and should not be submitted as a separate claim.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 99284 is not supported in the medical record. Specifically, the record shows the claim is duplicative with another claim already approved. Based on this information, we decided that Medicare rules for coverage of the Emergency Room Services have not been met.Therefore, we decided that the Plan does not have to pay for Emergency Room Services (99284) provided on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 1 power operated vehicle.
You asked the Plan to provide a Group 1 power operated vehicle. You say that the enrollee needs a PMD to get around. The Plan denied your request. The Plan says the record shows the enrollee is able to perform MRADLs and the PMD is requested for activities outside of the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee does not have a mobility deficit that impairs participation in MRADLs, and the condition can be improved by a cane. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a Group 1 power operated vehicle
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Group 1 power operated vehicle purchased on October 1, 2019.
You asked the Plan to reimburse you for the Group 1 power operated vehicle. You say that your scooter was not functioning and it was necessary to buy a new scooter immediately. The Plan denied your request. The Plan says the provider is not Medicare certified.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the Group 1 power operated vehicle purchased on October 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe ambulance transport provided on March 14, 2019.You asked the Plan to waive the copay forthe ambulance transport. You say that you should not be responsible for this cost share.The Plan denied your request. The Plan says that the claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copay for each covered, one-way ambulance trip by ground or water. You have been asked to pay a $295 copay for the ambulance transport. The ambulance transport falls within the covered, one-way ambulance trip by ground or water benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copay forthe ambulance transport provided on March 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99238) provided October 22, 2019.
You asked the Plan to pay for hospital discharge day management services. You say that this is the only discharge charge we have billed to you on this date of service form this physician so you have not previously paid and ask that you check your record history. The Plan denied your request. The Plan says payment for this post-operative visit was included in the payment for the surgical procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99238 was bundled as part of the global surgical fee because it was reported within 90 days of the major surgical procedure 54406 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99238) provided October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Group 3 power wheelchair and accessories.You asked the Plan to providea Group 3 power wheelchair and accessories. You say that the enrollee has difficulty ambulating and needs a Group 3 power wheelchair.The Plan denied your request. The Plan says the enrollee does not have a covered condition for a Group 3 power wheelchair.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to providea Group 3 power wheelchair and accessories.
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 October 8, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up appointment for inpatient surgery and you should not be charged a copayment. 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a home blood pressure monitor.
You asked the Plan to provide a home blood pressure monitor. You say that your doctor recommends a home blood pressure monitor. The Plan denied your request. The Plan says neither the Plan nor Medicare cover home blood pressure monitors for your condition.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to provide a home blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210) of teeth # 6 and 7, and the extraction (D7140) of tooth # 8 and the filling (D2330) for tooth # 9 provided from September 3, 2019 to October 10, 2019.
You asked the Plan to pay for the dental services. You say that the services should be covered. You say that the services were the result of a fall on September 2, 2019 that caused injury and damage to your mouth and teeth. You also say that the services should be covered the same way a medical injury would be. The Plan denied your request. The Plan says the extractions and the filling that you received are considered dental in nature. The Plan says that the claims processed correctly. The Plan also says that the dental services you received are not listed as covered services.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210) of teeth # 6 and 7, and the extraction (D7140) of tooth # 8 and the filling (D2330) for tooth # 9 provided from September 3, 2019 to October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on October 31, 2019.
You asked the Plan to waive the copayment for the arthrocentesis. You say that this was not surgery. You say that you shouldn't have to pay this much. 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 $150 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $150 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical procedure. 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 arthrocentesis provided on October 31, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on September 8, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you were informed you wouldn't have to pay a copayment. You say that you should not be responsible. 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 each Medicare-covered emergency room visit. You have been asked to pay $81.56, which is less than the standard $100 copayment for the ED visit. The ED visits falls within the "Emergency 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 the ED visit provided on September 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological and diagnostic services provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmological and diagnostic services. You say that the enrollee is an established patient and was seen in the office for his yearly exam. At the time of the visit the enrollee did not change his insurance information therefore no authorization obtained. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 for the ophthalmological and diagnostic services provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services
You asked the Plan to pre-approve the physician's services. You say that you saw this physician about four years ago for this medical condition. You say you feel more comfortable being treated by this physician because he has knowledge of your medical history. The Plan denied your request. The Plan says the services are available within the Plan's network of providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 5.You asked the Plan to pre-approve the dental service. You say that the enrollee is missing a crown on tooth # 5. You say that there is recurrent decay and build up would restore the decayed areas. You also say that it is vital and the tooth has good bone level.The Plan denied your request. The Plan says core build up is not listed as 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, core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control (E2331), push handles (K0108), an expandable control with necessary hardware (E2377, E2313, E2311), an enhanced steering control (K0108), cushion SmartCheck (K0108) and footplates (K0108) for use with an approved Group 3 power wheelchair (PWC).
You asked the Plan to pre-approve the requested PWC components and accessories. You say that the requested codes should be approved. The Plan denied your request. The Plan says all codes were approved aside from certain codes which are not separately reimbursable or do not serve a primarily medical purpose.
The Plan follows Medicare rules. Medicare rules say that wheelchair options/accessories are covered when reasonable and necessary and when the above referenced criteria are met. Equipment that is not primarily medical in nature does not meet the definition of durable medical equipment (DME) and cannot be 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 requested expandable controller specifically. Our reviewer says that the requested expandable controller is not shown to be medically reasonable and necessary. Our physician reviewer found the documentation notes that the plan approved group 3 power wheelchair with power tilt power recline and power elevating leg rests. The patient does not require the E2311 controller as the patient's right upper limb strength is sufficient for the patient to operate the controls with their own included power options already included in the allowance for these options. There is not a need to control the power options with a joystick, sip and puff or other non-proportional device, or to operate 3 or more actuators through the drive control. The patient does not require a separate display, an attendant control and other electronic devices. We also find that since the approved chair has a beneficiary-operated control, the attendant control is not covered additionally. Push handles are a convenience item and do not directly treat the enrollee's mobility deficit and are not considered DME. This is also applicable to the SmartCheck cushion feature which is not primarily medical. The enhanced steering control is an additional component of the expandable controller, which has been deemed not reasonable and necessary. The use of code K0108 would also not be appropriate for this component. Lastly, footplates are included in the approved power seating system and are not separately
payable with code K0108. Based on this review of the file, the Medicare rules, and our physician's review, we find that the coverage rule for these additional components have not been met. Therefore, we decided that the Plan does not have to pre-approve an attendant control (E2331), push handles (K0108), an expandable control with necessary hardware (E2377, E2313, E2311), an enhanced steering control (K0108),Cushion SmartCheck (K0108) and footplates (K0108) for use with an approved Group 3 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scooter repairs.
You asked the Plan to pre-approve the scooter repairs. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you are requesting review of denial of services.
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 scooter repairs have not been met. The Plan approved and paid for a scooter and scooter repairs. You received a scooter in October 2017 and repairs were performed in 2018. The repairs of the scooter exceed the cost of the scooter. The additional repairs are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve scooter repairs.