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

We decided that the Plan does not have to pay for the hearing aid (V5257) and related services (V5299, S9999).
You asked the Plan to pay for the hearing aid and related services. You say that the Plan should be willing to pay for the cheapest hearing aid option available. The Plan denied your request. The Plan says there is no coverage for hearing aids or related services if they are received from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased through the Plan's Hearing provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid and related services have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5257) and related services (V5299, S9999).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0481) provided on July 1, 2020
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was billed with a laboratory place of service code, but the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for drug testing services (G0481) provided on July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from July 20, 2020, through July 28, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you did not receive a benefit packet and were unaware of the cost. You say that you shouldn't owe this amount. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment per day for days 1-5 at an in-network hospital. After the 5th day, the Plan pays 100% of the covered expenses. You have been asked to pay a $1,475 copayment for the inpatient stay. ($295/day x 5 days = $1,475). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from July 20, 2020, through July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on November 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 had network providers
available who could have provided the services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network
provider on November 30, 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 these services are medically necessary. The Plan denied your request. The Plan says that your rehabilitation needs are not complex and do not require an interdisciplinary approach with multiple specialists to oversee your rehabilitation care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a
participating provider on January 19, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you think that you should
only have a $20 copayment. The Plan denied your request. The Plan says the correct copayment has been
applied.
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 $45
copayment for physician/practitioner services/in-network/specialist.
You have been asked to pay a $45 copayment for a specialist office visit. The correct copayment has bene
applied to the services that were provided. A specialist office visit falls within the physician/practitioner
services/in-network/specialist 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 specialist
office visit provided by a participating provider on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided August 28, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service where the specimen was obtained based on the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0482) provided August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on December 2, 2020.

You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The Plan says the correct copayment was applied to the claim.

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 Vision Care, for exams to diagnose and treat diseases and conditions of the eye by an Ophthalmologist. 

You have been asked to pay a $20 copayment for the physician's services. The physician's services falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physician's services provided on December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve suture of digital nerve of hand for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there are no recent clinical notes submitted documenting an injury to the right thumb.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee had an injury to her left index finger and now has hypersensitivity. The requested service is for the right thumb. The provided documentation does not support that the requested service is medically necessary and reasonable. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve suture of digital nerve of hand for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says the records don't support that the enrollee will need a stay of at least 25 days.

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 an epidural abscess. The enrollee is not intubated or 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 or 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 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 semi-electric hospital bed for the enrollee.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your
request. The Plan says while the supplied documentation may support a fixed height or even a variable height
hospital bed, it does not support the coverage criteria for a semi-electric hospital bed.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 bed. Our reviewer says that the
requested hospital bed is not medically reasonable or necessary. Our physician reviewer found the
documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not
feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does
not support a need for frequent or immediate change in body position or special attachments that cannot be
fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this
enrollee.

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 bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography (HCPCS C8928) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is needed before the echo stress test can be completed. The Plan denied your request. The Plan says the codes 93351 and C8930 have been approved and billing C8928 along with the approved codes would result in duplicate billing for the same service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

In this case, the CPT Code Manual definition of HCPCS code C8928 is "Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report."

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 services at issue in this case were not supported. Our physician reviewer found in this case, the plan has approved CPT code 93351. Approving HCPCS C8928 would be duplicative of what is already approved. The requested service cannot be recommended.

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 transthoracic echocardiography (HCPCS C8928) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bilateral medial branch blocks.

You asked the Plan to pre-approve bilateral medial branch blocks. You say that the requested bilateral medial
branch blocks are medically necessary. The Plan denied your request. The Plan says that the enrollee does not
meet criteria for the requested bilateral medial branch blocks.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 bilateral medial branch blocks. Our
reviewer says that the enrollee meets criteria for the requested bilateral medial branch blocks. Our physician
reviewer found the enrollee has chronic neck pain from cervical stenosis and facet arthropathy, status post
medial branch block (MBB) and radiofrequency ablation in the past with request for repeat MBB with steroids
bilateral C3-C4, C4-C5 and C5-C6. Per note, Left C3/4, C4/5, C5/6 Cervical Facet Injection provided
75% relief as a few weeks. Right C3/4, C4/5, C5/6 Cervical Facet Injection provided 40% relief 
but pain comes and goes left greater right pain. RFA LEFT C3, C4, C5, C6 MB provided
10% relief. RFA RIGHT C3, C4, C5, C6 MB provided 10% relief. The enrollee has apparently developed 
neuritis status post RFA.

Local anesthetic and Steroid injections at the Medial branches are appropriate for post RFA neuritis. This is
medically reasonable and 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 bilateral medial branch blocks have been met. Therefore, we decided that the
Plan has to pre-approve bilateral medial branch blocks.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a receiver, transmitter, and sensor (A9276, A2977, A9278) for use with a continuous glucose monitoring system.

You asked the Plan to pay for the supplies. You say that this is medically necessary. The Plan denied your request. The Plan says these items are part of a glucose monitoring system that fails to meet the requirements for durable medical equipment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that HCPCS A9276, A9277, and A9278 are not covered codes.

The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for a receiver, transmitter, and sensor (A9276, A2977, A9278) for use with a continuous glucose monitoring system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sheepskin boot (L2999).

You asked the Plan to pre-approve a sheepskin boot. You say that the requested care is a necessity for the
enrollee. The Plan denied your request. The Plan says the requested item is a non-covered orthosis.

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 a sheepskin boot. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the requested sheepskin boot cannot be classified as a concentric adjustable
torsion style mechanism. The requested equipment is not covered by Medicare when used to prevent or treat
heel pressure ulcers. This decision is in accordance with Medicare policy that establishes medical necessity for
use of static dynamic foot and/or ankle orthoses.

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 sheepskin boot have not been met. Therefore, we decided that the Plan does
not have to pre-approve a sheepskin boot (L2999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (PCD).
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no trial of the basic device.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the local coverage determination indicates, in relevant part, that a PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone. In this case, the record indicates the enrollee only as edema of the legs. The elements of the coverage determination are not 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (PCD).