Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 9 additional visits (for a total of 10 visits) for removal of devital tissue.
You asked the Plan to pre-approve additional visits for removal of devital tissue. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that treatment of ulcers are covered for certain indications. 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 10 visits for removal of devital tissue. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has had ongoing treatment for their left sacral pressure ulcer and right ilium pressure ulcer including weekly debridement appears to be helpful, although these ulcers were not resolved and require additional treatment. Based on the documentation provided showing a slow improvement related to treatment, ongoing weekly debridement is reasonable for at least 10 weeks. Therefore, this enrollee has a diagnosis that meet the criteria for additional debridement, and the request for 9 visits for removal of devital tissue will be considered 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 9 additional visits for removal of devital tissue have been met. Therefore, we decided that the Plan has to pre-approve 9 additional visits (for a total of 10 visits) for removal of devital tissue.
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. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an extremity study (93970).
You asked the Plan to pay for the extremity study. You say that you would like reconsideration as this service
was denied as a duplicate in error. The Plan denied your request. The Plan says this claim matches a previous
claim's member, provider, procedure code, date of service, quantity and billed amount.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the extremity study have not been met. Specifically, the record indicates that this claim is an exact
duplicate of another that has already been processed and paid. Therefore, we decided that the Plan does not
have to pay for an extremity study (93970).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra battery for a portable oxygen concentrator for the enrollee.
You asked the Plan to pre-approve an extra battery. The Plan denied your request. The Plan says that Medicare and the Plan do not cover an extra set of batteries.
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 an extra battery for a portable oxygen concentrator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay.
You asked the Plan to waive the copayment for the inpatient stay. You say that you didn't know he was going to stay that long. You say that you don't have that type of money. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $320 copayment per day for days 1-5. Cost sharing is charged for each inpatient stay. The enrollee has been asked to pay a $1,600 copayment for the inpatient stay. ($320/day x 5 days = $1,600). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens fitting provided on May 17, 2019.
You asked the Plan to pay for the contact lens fitting. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $100 eyewear allowance per calendar year.
We looked at the file and the Plan's rules. Review of the file shows that the plan paid $65 for the eyewear
services received on December 26, 2019. Therefore, the remaining balance of the $100 eyewear allowance is
$35. $35 was put toward the purchase of eye services received on May 17, 2019. $50 was billed for the services
received on May 17, 2019, therefore, you owe the difference of $15. Based on this information, we decided that
the Plan's rules for coverage of the contact lens fitting have not been met. Therefore, we decided that the Plan
does not have to pay for the contact lens fitting provided on May 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence wipes.
You asked the Plan to pre-approve incontinence wipes. The Plan denied your request. The Plan says that this is
not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence wipes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 11, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this appeal reprocessed and
approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network.
The Plan says that the no prior authorization was obtained.
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 physician services provided on December 11,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the initial hospital care rendered on November 24, 2019.
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 that the procedure code is not appropriate for the submitted place of service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that procedure code 99223 (initial hospital care) is not
appropriate for the place of service (POS) submitted. The file shows that the billed POS code is 21 for inpatient
hospital. There is no documentation or Medicare rules presented by the Plan to support that the claim is not
payable as billed. Therefore, we decided that the Plan has to pay for the initial hospital care rendered on
November 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 15% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $3,413.00, which is less than the 15% coinsurance amount for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast reduction surgery.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no mention of weight loss to reduce pain, nor is there any work-up to see if there is an underlying reason for the obesity.
The Plan must follow Medicare rules. Medicare rules say that breast reduction surgery is covered if there symptoms lasting over six months that have not responded to conservative 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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found you have significantly enlarged breasts, and the presence of at least two of the covered symptoms. You have shoulder grooving, and upper extremity paresthesias (right ulnar neuropathy) likely related to her enlarged breasts/shoulder straps. You have upper back shoulder and neck pain that appears directly correlated to the macromastia. These symptoms have lasted greater than a year at least, and have not responded to a reasonable non-surgical program, which included medical management, physical therapy and supporting bras for a greater than 6 month period.
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 surgery have been met. Therefore, we decided that the Plan has to pre-approve breast reduction surgery.
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. If we 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 anesthesia services (01230) provided on September 3, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include the patient's name on the anesthesia record. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Specifically, the documentation submitted did not include the member's name on the anesthesia record. We are unable to corroborate the documentation in the beneficiary's medical documentation to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (01230) provided on September 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for daily skilled services or inpatient services. Care in the home or an assisted living facility with home health services appears to be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture.
You asked the Plan to pre-approve the mandibular partial denture. You say that your gums have shrunk, you have no lower dentures, and are unable to eat properly. You also say that your gums hurt a lot when you try to chew with them. The Plan denied your request. The Plan says your plan does not cover this procedure.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sacroiliac joint injection provided on January 6, 2020. 
 
You asked the Plan to waive the copayment for a sacroiliac joint injection. You say that you have had this procedure done in the past and there was no copayment. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $250 copayment for a sacroiliac joint injection. A sacroiliac joint injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a sacroiliac joint injection provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmic biometry by ultrasound echography (76519).
You asked the Plan to pay for the vision services. You say that CPT code 76519 is in group 1. Diagnosis code
H25.041 is under group 1 which states this diagnosis code billed with that CPT code establishes medical
necessity. Please review and reprocess for payment. The Plan denied your request. The Plan says 2 or more
diagnosis codes are mismatched. It is not appropriate to report unspecified, or left and right diagnosis codes
when a more specific code is available.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the vision services have not been
met. Therefore, we decided that the Plan does not have to pay for ophthalmic biometry by ultrasound
echography (76519).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 10, 2019 through December 13, 2019. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that he is disabled and cannot afford it. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $320 copayment per day for days 1-5. Cost sharing is charged for each inpatient stay. 
 
The enrollee has been asked to pay $640, which is less than the standard copayment for the three-day inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 10, 2019 through December 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on
December 5, 2019.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you were not
informed that you would owe such a high copayment. 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 $350
copayment for each nuclear medicine study.
You have been asked to pay a $350 copayment for myocardial perfusion imaging. Myocardial perfusion
imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for myocardial perfusion imaging provided on December 5,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided  on November 15, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were provided in good faith. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 physician services provided  on November 15, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compressor and appliances provided by Restorative Medical Supply on April 3, 2019. 
 
You asked the Plan to pay for the pneumatic compressor and appliances. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the delivery ticket was not itemized to indicate the specific supplies therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.  
 
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket. Therefore, we decided that the Plan does not have to pay for the pneumatic compressor and appliances provided by Restorative Medical Supply on April 3, 2019.