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

We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on January 22, 2020.
You asked the Plan to pay for the CGM. You say that the records provided support the need for the requested CGM. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 pay for the CGM. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not show that the enrollee uses insulin or has been using a blood glucose monitor and performing four or more tests per day. The documentation provided does not show why the enrollee is not able to continue the finger sticks glucometer method of checking her blood glucose for monitoring. The documentation does not show why the enrollee's glucometer method is not adequate anymore. 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 CGM have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a (E2402) Negative Wound Pressure Vaccuum and Supplies
(A6550 & A7000).
You asked the Plan to pay for a negative pressure wound therapy pump (NPWT). You say that the enrollee
should get the device. The Plan denied your request. The Plan says the enrollee is not engaging in
comprehensive diabetic management program.
The Plan follows Medicare rules.
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 pay for a negative pressure wound therapy pump
(NPWT). Our reviewer says that the services at issue do not meet Medicare criteria for coverage. Our physician
reviewer found no mention of lifestyle efforts with diet or exercise were noted as regularly being utilized. A
need for better and more comprehensive diabetes management is apparent based on the provided
documentation. As the use of a wound vacuum is not going to be as productive in the setting of poor diabetes
management such as in this case, use of this device now would be inappropriate. Better control of the patients
diabetes via lifestyle and medical management is needed prior to considering this 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 a negative pressure wound therapy pump (NPWT) have not been met.
Therefore, we decided that the Plan does not have to pay for a (E2402) Negative Wound Pressure Vaccuum
and Supplies (A6550 & A7000).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services provided to the enrollee on
September 4, 2019.
You asked the Plan to pay for the services. You say that you are merely asking for the Plan to approve the
services and reprocess the claim for payment. The Plan denied your request. The Plan says all referrals and
authorizations require coordination by the assigned PCP.
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 the office visit services provided to the enrollee on
September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the supplies are medically necessary due to a medical condition. 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 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 supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic exam and evaluation provided on January 23, 2020.
You asked the Plan to waive the copayment for the exam. You say that you were told eye exams are covered once per year. The Plan denied your request. The Plan says that you are responsible for the 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 $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes. You have been asked to pay a $35 copayment for the exam. The exam falls within the Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes 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 ophthalmic exam and evaluation provided on January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for medication provided on a cruise ship on January 8, 2020. You asked the Plan to pay for this claim. You say that the Plan should cover these medications. The Plan denied your request. The Plan says Medications dispensed by cruise ships are not covered. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs appealed are not among the types which are covered by Medicare Part B. The Plan does not cover medications provided outside of the United States. Medications provided on cruise ships are not regulated by Medicare and are not covered by the Plan. Therefore, we decided that the Plan does not have to pay for medication provided on a cruise ship on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that this care will be provided by an endovascular neurosurgical radiologist who regularly performs minimally invasive procedures that cannot be done by a simple neurologist, neuroradiologist, neurosurgeon, or radiologist. You say that these highly specialized and delicate procedures need to be done by a physician who had additional training in endovascular neurosurgical radiology and you not only had training in a sub-specialty but had additional 2-3 years of training in this highly sub specialized field. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional units of CPT codes 72148 and 72141 billed on
January 29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services were
already paid for this date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code is not supported in the medical record. Specifically, the records provided only show that
one MRI of the lumbar spine and one MRI of the cervical spine were performed on the date of service in
question. The plan previously paid for these services. The records do not support a second unit of each of these
codes for January 29, 2020. 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 pay for the additional units of
CPT codes 72148 and 72141 billed on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), the x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbar spine (72100) provided January 8, 2020 and January 13, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
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 office visit (99203), the x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbar spine (72100) provided January 8, 2020 and January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that the orthotics were desperately needed due to the multiple surgeries that you have had on your foot. You say that you experienced significant pain in your foot and after trying medication and physical therapy, your podiatrist recommended custom foot inserts. After you received the inserts and slowly began using them more to break them in, you found that they helped reduce the pain you had been experiencing. You say that in time, you no longer experienced pain when you took a step. You stated that the inserts were medically necessary and asked the Plan to reconsider providing coverage for them. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the physical therapy visit provided on January 31, 2020. 
 
You asked the Plan to reduce the copayment for the physical therapy visit. You say that your physical therapy visit was at your doctor's specialist office and not an outpatient hospital. 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 $40 copayment for physical therapy at an in-network outpatient hospital.  
 
You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation services" benefit category. The record shows you were billed by an outpatient hospital. 
 
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 reduce the copayment for the physical therapy visit provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336), and the blood pressure reading (G8783) rendered by the out of network (OON) provider on December 27, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 domiciliary or rest home visit for the evaluation and management of an established patient (99336), and the blood pressure reading (G8783) rendered by the out of network (OON) provider on December 27, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that you need these services due to dementia. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered. We looked at the file and Medicare rules. The file shows that these services have been requested for help with bathing, chores, and other activities of daily living. These services are custodial in nature. The file also does not show that you are receiving or that you require qualified skilled services. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on
November 19, 2019.
You asked the Plan to pay for the moderate sedation 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 supported by the
documentation.
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 99152 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted
did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level
of consciousness and physiological status; therefore, the billed service cannot be verified. Based on this
information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.
Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152
provided on November 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan coded 71250 provided on January 21, 2020. 
 
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. 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 71250 is computed tomography, thorax; without contrast material. 
 
We find that CPT code 71250 is not supported in the medical record. Specifically, this code was only billed with diagnosis code Z01.89 (Encounter for other specified special examinations). This code should be reported for routine laboratory/radiology testing in the absence of any signs of associated diagnosis. The services were rendered in an emergency room, an outpatient non-routine setting, therefore, this diagnosis code should be accompanied by the corresponding procedure code. 
 
Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the CT scan coded 71250 provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from October 23, 2018, to May 16, 2019.
You asked the Plan to pay for the services. You say that you thought this would be processed as out-of-network. The Plan denied your request. The Plan says this provider does not accept Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider that has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the services you received from October 23, 2018, to May 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from January 1, 2020 to January 16, 2020. You asked the Plan to waive the copayment for the SNF stay. You say that you were not informed that you would be there past 20 days and was not informed that there would be a cost past the 20 days. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day per admission for days 1 to 20 and a $178 copayment per day per admission for days 21 to 100. The enrollee has been asked to pay a $712 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) 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 SNF stay provided from January 1, 2020 to January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on December 30, 2019. You asked the Plan to waive the copayment for vision care. You say that you received a routine eye exam 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 a $35 copayment for exams to diagnose and treat diseases and conditions of the eye. The medical records show that you received services beyond a routine eye exam on December 30, 2019. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for vision care. Vision care 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 vision care provided on December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 26, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you were not told the services wouldn't be covered. The Plan denied your request. The Plan says the services were rendered by an OON provider without prior authorization. 
 
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 the medical services provided on September 26, 2019 by an out of network (OON) provider.