Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) and single vision lenses (V2100) purchased November 22, 2019.
You asked the Plan to pay for the frames and lenses. You say that this was processed incorrectly because the plan did not pay for the discounted, coupon amount and the plan should pay the full amount. The Plan denied your request. The Plan says the allowance does not reimburse for discounted amounts for which no payment by the enrollee was made.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that the plan covers up to $300 allowance for non-Medicare covered eyewear a year.
You have asked the plan to pay an additional $58.50. You paid $175.50 for the eyewear purchase. The records show that $58.50 was discounted due to a coupon and you paid $175.50 for the frames and lenses. The plan reimbursed you the amount that you paid. The frames and lenses falls within the Vision care benefit category. 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 pay for deluxe frames (V2020) and single vision lenses (V2100) purchased November 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for retina scanning (92134) provided on May 24, 2019.
You asked the Plan to pay for the retina scanning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed 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. In this case, the CPT Code Manual definition of code 92134 is scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina report. 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 retina scanning. Our reviewer says that CPT code 92134 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina report for May 24, 2019, therefore, this service cannot be verified. 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 retina scanning have not been met. Therefore, we decided that the Plan does not have to pay for retina scanning (92134) provided on May 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99204), neuromuscular
reeducation (97112), therapeutic exercises (97110), and electrical stimulation (G0283) provided from
September 27, 2019 to December 18, 2019.
You asked the Plan to pay for a chiropractic office visit, neuromuscular reeducation, therapeutic exercises,
electrical stimulation. You say that the services you need are not available from other providers. The Plan
denied your request. The Plan says these services are not covered when provided by a chiropractor.
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 a chiropractic office visit (99204), neuromuscular reeducation (97112),
therapeutic exercises (97110), and electrical stimulation (G0283) provided from September 27, 2019 to
December 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
October 2, 2019 to October 30, 2019.
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says payment
is not appropriate for the type of bill (TOB) billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. The claims provided did not show they were
billed with a valid type of bill. Based on this information, we decided that Medicare rules for completing the
claim for the home health services have not been met. Therefore, we decided that the Plan does not have to pay
for the home health services provided to the enrollee from October 2, 2019 to October 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the face.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says the CT and MRI of parts of the face were already normal, there are no symptoms of a
life-threatening problem.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found there has been no
documented change in the facial/orbital soft tissue swelling since January. The notes say that prior imaging
including the January, 2020 MRI is not available. It seems more than reasonable to determine the outside
facility where the prior MRI had been done, have the patient sign a release, and request the report and images
be sent to the requesting physician for review prior to deciding a repeat MRI is indicated at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI of the face.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for a thigh wound. The enrollee has received wound debridement and completed a course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.
You asked the Plan to pre-approve a power wheelchair (K0842). You say that the enrollee needs a power wheelchair. The Plan denied your request. The Plan says a power wheelchair is not medically necessary.
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.
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 a power wheelchair (K0842). Our reviewer says that a power wheelchair not medically necessary. Our physician reviewer found the enrollee is unable to transfer or ambulate independently. The enrollee has super morbid obesity and lower extremity weakness with shoulder arthritis and is unable to use a walker, cane, or manual wheelchair. The member had previously used a scooter. Providing the enrollee with a scooter would be expected to address her mobility-related impairments. Providing her with a power wheelchair is not reasonable or 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 a power wheelchair (K0842) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided to the enrollee on November 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG paymentto the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided to the enrollee on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the 3-monthsupply of urinary intermittent catheter w/insertion kits provided on December 13, 2019.You asked the Plan to pay for the 3-monthsupply ofurinary intermittent catheter w/insertion kits. You say that the Plan approved the high quantity usage on March 14, 2019.The Plan denied your request. The Plan says that the usual maximum quantity for one month is200 per month and the provider has billed for a 3-monthsupply.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. There is no LCD or Policy Article documentation of having to bill one month at a time for these supplies.The quantity was approved by the Plan. Based on this information, we decided that Medicare rules for coverage of urinary intermittent catheter w/insertion kits have been met.Therefore, we decided that the Plan has to pay for the 3-monthsupply ofurinary intermittent catheter w/insertion kits provided on December 13, 2019.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. Ifwe decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic services provided by a chiropractor from
October 23, 2019 to November 13, 2019.
You asked the Plan to pay for the therapeutic services. The Plan denied your request. The Plan says Medicare
does not cover non-manipulative services provided by chiropractors.
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 therapeutic services (CPT Code 97150) at issue are not manual manipulation of the
spine. Therefore, we decided that the Plan does not have to pay for the therapeutic services provided by a
chiropractor from October 23, 2019 to November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services for the enrollee. You asked the Plan to pre-approve the services. You say that it is not fair that the provider is not paid for these services. The Plan denied your request. The Plan says the plan does not provide coverage for maintenance care. The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the submitted pain intensities of February 22, 2020 and March 21, 2020 reveal a pain level of one, which is minimal, does not require treatment and does not indicate significant health problem in the form of a neuro musculoskeletal condition. In addition, the submitted chart notes reveal the same or similar complaints, findings, treatment rendered and diagnoses, with treatment on a monthly basis. Medicare guidelines state that maintenance therapy is when further clinical improvement cannot reasonably be expected from continuous ongoing. This is maintenance therapy, which is not supported or allowed per Medicare guidelines. Additionally, the submitted chart notes of February 22, 2020 and March 21, 2020 reveal palpation findings of tenderness and hypertonicity of a number of muscles, fixation levels, a short leg and a positive orthopedic test. These findings do not reveal evidence of subluxation per Medicare guidelines. Thus, chiropractic treatment is neither supported nor allowed per Medicare guidelines. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the application of an arm splint provided on April 12, 2019.
You asked the Plan to waive the copayment for the application of an arm splint. You say that this was a follow-up after a surgery and 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 each covered in-network specialist office visit. You have been asked to pay a $50 copayment for the application of an arm splint. The application of an arm splint 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 application of an arm splint provided on April 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 4, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not contain evidence of a relationship with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records form the ordering physician supporting medical necessity. Based on this information, we decided that Medicare rules for coverage of the knee orthoses
(L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 27, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this service.
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 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 subsequent nursing facility care provided on December 27, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 24, 2019 to October 30, 2019.
You asked the Plan to pay for home health 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. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, a Federal Information Processing Standards (FIPS) code is required to identify the county where the services were rendered. The claim submitted is missing this required information. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 24, 2019 to October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 23, 2018.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered on October 23, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says that a Group 2 power wheelchair would be more medically appropriate.
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. 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 a power scooter. Our reviewer says that a power scooter is not medically reasonable and necessary in this case. The information provided does not confirm that your mobility related activities of daily living cannot be met through the use of standard mobility aides. Our physician reviewer found that your condition does not meet Medicare criteria for coverage of a power scooter. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ablation therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ablation therapy. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve ablation therapy to be provided by an out of network (OON) provider.