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

We decided that the Plan does not have to pay for the intravenous (IV) tubing and infection control supplies
rendered on August 19, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.

We looked at the file and Medicare rules. Billed procedure codes S1015 and S8301 have a status indicator of I
and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the
intravenous (IV) tubing and infection control supplies rendered on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on August 3, 2020.

You asked the Plan to pay for the chiropractic services. 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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder brace (L3960).

You asked the Plan to pay for a shoulder brace. You say that the item should be covered. The Plan denied your
request. The Plan says you did not present any medical records showing that the prescribing physician ever saw
the member.

The Plan must follow Medicare rules. 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.

The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The medical records are not signed by the ordering physician and the Plan has not received a claim
from the ordering physician. Therefore, we decided that the Plan does not have to pay for a shoulder brace
(L3960).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray (71046).

You asked the Plan to waive the copayment for the x-ray. You say that the bill should be covered in full by your insurance. The Plan denied your request. The Plan says x-ray exams have a $14 copayment.

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 $14 copayment for Medicare-covered x-ray services.

You have been asked to pay a $14 copayment for the x-ray. An x-ray 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 the chest x-ray (71046).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says bone marrow aspiration is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of bone marrow aspirate remains experimental in nature for use in spinal fusion surgery. More research is needed to show safety and efficacy. The requested services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block injections.

You asked the Plan to pre-approve genicular nerve block injections. You say that this service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary as studies do not show this procedure is effective.

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 genicular nerve block injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested service is considered an experimental/investigational procedure whose place in clinical algorithms has not been established. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block injections have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).

You asked the Plan to pay for the comprehensive oral evaluation. You say that you needed to see a new provider because your previous dentist would not work with you. You also say that you are on a limited income. The Plan denied your request. The Plan says this service exceeds maximum allowed per period.

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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150), and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous spacer (22870, 22869).

You asked the Plan to pre-approve the insertion of a Superion interspinous spacer. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Superion interspinous spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. 

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 insertion of a Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous spacer (22870, 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all
four quadrants.

You asked the Plan to pre-approve the dental services. You say that you do not want to lose your teeth. You say
that your gums are bleeding and infected. You say that you have three cavities. You say that your gums bleed
every time you brush your teeth. You also say that your teeth hurt when you eat due to the cavities under the
crown and bridges which also need to be cleaned. The Plan denied your request. The Plan says periodontal
scaling and root planing 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, 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
periodontal scaling and root planing (D4341) for all four quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound debridement services (11045).

You asked the Plan to pay for the debridement services. You say that please review information for denial of
CPT 11045 for number of services not supported. The Plan denied your request. The Plan says there is
insufficient documentation to corroborate the service and confirm that the Medicare coverage criteria has been
met.

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 11045 is Debridement, subcutaneous tissue (includes
epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to
code for primary procedure).

We find that CPT code 11045 is not supported in the medical record. Specifically, there is no physician's order
and no documentation on a referring provider or how the enrollee came to you. There is no documentation that
the services were medically necessary. The records show that the Plan made multiple attempts to obtain the
additional information needed from the provider and none was received. Based on this information, we decided
that Medicare rules for coverage of the debridement services have not been met.

Therefore, we decided that the Plan does not have to pay for the wound debridement services (11045).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the vacuum drainage collection unit and tubing kit (A7048).

You asked the Plan to pay for the vacuum drainage collection unit and tubing kit. You say that you are requesting reconsideration of the denial and providing adequate documentation of medical necessity of correctly reported units for review and payment. The Plan denied your request. The Plan says the number of units allowed for this service under Medicare rules has been exceeded. the documentation does not support the 30 units billed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, you billed for 30 units of A7048, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the vacuum drainage collection unit and tubing kit have not been met. Therefore, we decided that the Plan does not have to pay for the vacuum drainage collection unit and tubing kit (A7048).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a urethral dilation procedure (53605)
provided on July 1, 2020.

You asked the Plan to waive the copayment for a urethral dilation procedure. You say that you do not believe
this service was performed. The Plan denied your request. The Plan says this service 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 $20
copayment for Medicare-covered surgery services.

You have been asked to pay a $20 copayment for a urethral dilation procedure, which is considered a surgical
service. The medical records submitted by your provider confirm that this service was performed. 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 urethral dilation procedure (53605) provided on July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The
Plan denied your request. The Plan says admission to an IRF is not medically necessary.

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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the
patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Finally,
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower limb prosthetic vacuum pump (L5781).

You asked the Plan to pre-approve the lower limb prosthetic vacuum pump. You say that this is medically necessary. The Plan denied your request. The Plan says this service exceeds the member's needs.

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 lower limb prosthetic vacuum pump. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member requires a new prosthetic leg socket as her previous prosthesis no longer fits well. The Plan has authorized a new prosthetic leg socket. The documentation doesn't support that a specific VASS (Vacuum-assisted socket system) is medically necessary for the member. The requested system appears to be in excess of what would be considered as medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lower limb prosthetic vacuum pump have not been met. Therefore, we decided that the Plan does not have to pre-approve the lower limb prosthetic vacuum pump (L5781).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the Magnetic Resonance Imaging (MRI) scans, a Computed Tomography (CT) scan, and related contrast material injections provided from May 14, 2020 to August 3, 2020.

You asked the Plan to waive the cost-sharing for the MRI and CT scans. You say that you were only expecting to pay for the office visit with a specialist and do not understand where the extra charges are coming from. The Plan denied your request. The Plan says radiological diagnostic services such as MRIs and CT scans each have a $125 copayment. Additionally, there is a 20% coinsurance for medical supplies used with these exams.

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 $125 copayment for each radiological diagnostic service other than an x-ray. 

You have been asked to pay a $125 copayment for each of the MRI and CT scans. You received an MRI of the brain (70553), neck and spine (72156), chest spine (72157), and lumbar spine (72158) in addition to a CT scan of the abdomen and pelvis (74178). Each of these services has a $125 copayment ($125 x 5 scans = $625). MRI and CT scans fall within the radiological diagnostic services other than x-rays benefit category.

In addition, injection dye and contrast materials (A9579, Q9967) were used with these scans. You have been asked to pay a 20% coinsurance for each of these. The Plan's allowed amount for the contrast material used with the CT scan is $12. You have been asked to pay $2.40 ($12 x 20% = $2.40). The Plan's allowed amount for the dye used with the MRI scans is $22.95. You have been asked to pay $4.59 ($22.59 x 20% = $4.59). Both of these substances are considered chemical agents used in certain diagnostic procedures and have a 20% coinsurance.

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 cost-sharing for the MRI scans, CT scan, and related injections provided from May 14, 2020 to August 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. The 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. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 x-rays.
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.

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 billed are not payable.

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, the claim was billed with an invalid HIPPS codes for the services billed. No revenue codes 027x with NRS was billed and per hipps sheet there is no active medicare payment through date. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 17, 2020.

You asked the Plan to pay for the physician service. You say that the service was necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on May 4, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the medical services provided on May 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the disposable underpads (A4554) and skin sealants,
protectants, moisturizers, ointments, any type, any size (A6250).

You asked the Plan to pay for incontinence and urology supplies. You say that you do not understand the plan
claiming these disposable items are not covered, but has been covering your disposable items for years. The
Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence is not covered because
they are hygienic items that are non-reusable.

While incontinence and urology 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 pay for the disposable underpads
(A4554) and skin sealants, protectants, moisturizers, ointments, any type, any size (A6250).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 9, 2020 to September 22, 2020.

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 billed are not payable.

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, the billed charges are Home Health Skilled Nursing services and must be reported on HH PPS claims with the corresponding revenue code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 9, 2020 to September 22, 2020.