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

We decided that the Plan does not have to waive the coinsurance for the nebulizer provided on October 8, 2019.
You asked the Plan to waive the coinsurance for the nebulizer. You say that you were given the nebulizer at the hospital told it would be free. The Plan denied your request. The Plan says the nebulizer is covered and you have been charged this coinsurance 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the nebulizer. The nebulizer falls within the durable medical equipment and related 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 coinsurance for the nebulizer provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and the electrical connection between the power wheelchair and two or more motors (E2311).
You asked the Plan to pre-approve an expandable controller, harness, and the electrical connection between the power wheelchair and two or more motors. You say that these items should be covered. The Plan denied your request. The Plan says there is not a medical need to control the power options through a joystick.
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 an expandable controller, harness, and the electrical connection between the power wheelchair and two or more motors. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you require a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. Your strength in the left upper extremity is sufficient to control the power options with their separate switches already included with the approval of these power options. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness, and the electrical connection between the power wheelchair and two or more motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and the electrical connection between the power wheelchair and two or more motors (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care is still needed in the acute care hospital setting.
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 ACH. Initially treated for a kidney stone, the enrollee was subsequently treated for aspiration and ARDS. The enrollee has received antibiotics and supplemental oxygen. The enrollee is not intubated/ventilated. 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 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not need to be seen by a provider three times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that the enrollee's current level of function is minimal to moderate assist for bed mobility, moderate assist for transfers, upper body and lower body transfers, and ambulation with a rolling walker. The enrollee had no chest pain, shortness of breath, or dizziness. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level in an IRF. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on July 18, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were not told you would be
responsible for a $150 copayment. You say you already pay too much for medications. 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 $150
copayment per visit for Medicare-covered outpatient hospital services.
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the "Outpatient
hospital services" benefit category. The record shows you were billed by the hospital for the CT scan.
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 CT scan provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dobutamine HCI (J1250), Heparin Sodium (J1644), a flush (A4216), infusion supplies (A4221 and A4222) provided on July 31, 2019 through August 6, 2019.
You asked the Plan to pay for the infusion services. 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 substantiate how the member came to the servicing provider or whether the services were medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met. Specifically, the record does not include sufficient information to determine whether payment is due and the amount of payment. Therefore, we decided that the Plan does not have to pay for dobutamine HCI (J1250), Heparin Sodium (J1644), a flush (A4216), infusion supplies (A4221 and A4222) provided on July 31, 2019 through August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular surgery interventions to be performed based on the results of an angiogram.
You asked the Plan to pre-approve the possible vascular surgery interventions. You say that this needs to be approved in order to prevent possible loss of the limb. The Plan denied your request. The Plan says the angiogram has been approved. The surgeon may perform interventions which are deemed medically necessary based on the findings, which will be reviewed retrospectively. No prospective decision can be made since the results of the angiogram are not known.
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 possible vascular surgery interventions. Our reviewer says that the requested interventions are not considered medically reasonable and necessary in this case since the results of the angiogram are unknown. Our physician reviewer found there is documentation of ulcers of the right foot, with absent pedal pulses and non-compressible (abnormal) tibial arteries. There is appropriate concern that these are signs of limb threatening ischemia. A very reasonable next step is diagnostic angiography and possible intervention based on the results of the angiogram. The provider is requesting preapproval of coverage for the possible intervention(s), the details of which cannot be known until the time the angiogram is performed. The plan has approved an angiogram for this enrollee. The plan has indicated that interventions performed based on the results of the angiogram will be approved retrospectively if medically necessary, but cannot be approved prior to the results of the angiogram. 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 possible vascular surgery interventions have not been met. Therefore, we decided that the Plan does not have to pre-approve vascular surgery interventions to be performed based on the results of an angiogram.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reduction mammoplasty.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted medical records do not show that enough breast issue will be removed.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria note that there should be documentation of failure of conservative measures. This has not been documented. The medical documentation does not support that her pain from macromastia has been unrelieved by conservative analgesia, supportive measures and/or physical therapy. The degree of resection of 200-300 grams does not specifically exclude a medically necessary breast reduction. However, this degree of resection in combination with a lack of conservative measures attempted, supports that Medicare medically necessary criteria have not been 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a reduction mammoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 18, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 18, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services (99233) provided October 8 to October 9, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary and
billed correctly. The Plan denied your request. The Plan says that payment for the physician services was
bundled with the surgical procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 99233 is supported in the medical record. Specifically, there is no documentation of a
signed transfer agreement between the surgeon and the physician who performed the services at issue. This
means that the physician services are not considered to be part of the Global Surgical period. Based on this
information, we decided that Medicare rules for coverage of the physician services have been met. Therefore,
we decided that the Plan has to pay for physician services (99233) provided October 8 to October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for measurement of post-voiding residual urine (51798) provided on September 26, 2019 by out of network provider.
You asked the Plan to pay for measurement of post-voiding residual urine. You say that you are appealing the denied claim as the notes will support the need for service. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The plan did not authorize any services for the out of network provider. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 measurement of post-voiding residual urine (51798) provided on September 26, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 CFR 422.101.
The rules state that coverage and payment for Medicare telehealth services includes consultation, office visits,
individual psychotherapy, and pharmacologic management delivered via a telecommunications system.
Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as
a metropolitan statistical area (MSA). The originating site for telehealth services (location to which the enrollee
presents) must be a practitioner's office, hospital, rural health clinic (RHC), federally qualified health center
(FQHC), skilled nursing facility or community mental health center. You can find this rule in the Medicare
Claims Processing Manual, Chapter 12, Sections 190.1 and 190.2.
The rules say that for eligible telehealth services, telecommunications systems substitute for an in-person
encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating
site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional
Shortage Area (HPSA) located in a rural census tract. You can find this in the CMS MLN document entitled
"Telehealth Services."
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on February 28, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on February 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost sharing amount for the crown (D2740) and the resin based composite (D2391) provided on June 20, 2019.
You asked the Plan to pay the full cost sharing amount for the dental services. You say that you were unaware that a deductible was applied to the dental rider. You say that you had the understanding that the plan covered up to $1500 towards dental services. You also say that you were expecting the Plan to pay for most of the cost of the crown. The Plan denied your request. The Plan says the cost share was applied correctly. The Plan also says since the provider is out of network, the Plan pays according to a maximum allowable fee schedule and you are responsible for all fees in excess of that amount from the billed amount.
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 cost sharing amounts were paid correctly as the services were received out of network. For services received out of network, you are responsible for the cost share amount, remaining deductible, and the difference between the billed amount and allowed amount for each service. Therefore, we decided that the Plan does not have to pay the full cost sharing amount for the crown (D2740) and the resin based composite (D2391) provided on June 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on August 22, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you required the ambulance due to complications during a procedure. 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for an ambulance trip. An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided on August 22, 2019.