Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood smear provided to the enrollee on February 10, 2020. You asked the Plan to pay for the blood smear. You say that this should be paid for. The Plan denied your request. The Plan says there is no payment for this code furnished to hospital outpatients for a physician. 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 85060 is "Blood smear, peripheral, interpretation by physician with written report." We asked our coding 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 blood smear. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT 85060 has a Professional Component /Technical Component Indicator of 8. This means the professional component of clinical laboratory codes can be reimbursed separately if the physician interprets an abnormal smear for hospital inpatient. Billing 85060 without a modifier to determine if you are seeking payment for professional or technical component of the services would imply you are seeking payment for both the profession and technical portion of the service. Therefore, based on place of service billing for CPT 85060 in billed inappropriately and is not eligible for reimbursement consideration. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the blood smear have not been met. Therefore, we decided that the Plan does not have to pay for a blood smear provided to the enrollee on February 10, 2020.
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 you need the supplies but cannot afford them. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle. You asked the Plan to pre-approve a Group 1 power operated vehicle. You say that you need a Group 1 power operated vehicle to get into doctor's offices. The Plan denied your request. The Plan says Medicare will not cover a power operated vehicle if you are able to use a walker to move around your house. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker. This means that Medicare rules for coverage of a PMD have not been met. Also the item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover POVs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide group 1 heavy duty power operated vehicle (POV).
You asked the Plan to provide group 1 heavy duty power operated vehicle (K0801). You say that the enrollee
needs a power operated vehicle. The Plan denied your request. The Plan says this is not the correct power
operated vehicle for the enrollee.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file shows that the enrollee does not meet the weight criteria. This means that Medicare rules for coverage
of a POV have not been met. Therefore, we decided that the Plan does not have to provide group 1 heavy duty
power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gym membership purchased November 25, 2019.
You asked the Plan to pay for the gym membership. You say that the closest plan approved gyms are more than
18 miles from where you live. You request reimbursement for a very reasonable fee you pay for membership
only 5 minutes form your house. The Plan denied your request. The Plan says this fitness center is not a
participating fitness center and does not participate in SilverSneakers program.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits
only when provided by a network fitness facility.
The Plan's rules for coverage of gym benefits have not been met because this fitness center is not a
participating fitness center. Therefore, we decided that the Plan does not have to pay for gym membership
purchased November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty Group 3 power wheelchair. You asked the Plan to pre-approve a heavy duty Group 3 power wheelchair (K0858). You say that the enrollee needs a heavy duty Group 3 power wheelchair. The Plan denied your request. The Plan says the enrollee's weight does not meet criteria. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee does not meet the weight criteria for this PMD. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty Group 3 power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a push-rim activated power assist device. You asked the Plan to pre-approve the manual wheelchair push-rim activated power assist device. You say that you tire easy and need the push-rim activated power assist device. The Plan denied your request. The Plan says you have not been self-propelling in a manual wheelchair for at least one year. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the manual wheelchair push-rim activated power assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve a push-rim activated power assist device.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on November
26, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were charged too much
for the urgent care visit because little was done during the visit. 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 covered services to an in-network or out-of-network medical facility or urgent care center per
visit.
You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent
care visit provided on November 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 additional physical therapy visits (97110).
You asked the Plan to pre-approve 14 additional physical therapy visits. You say that the services are
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore,
coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 14 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is generally not
accepted as specific and effective therapy for your condition. The documentation notes you are already
compliant in a home exercise program. The records do not reveal significant objective measures of functional
improvement. The records do not demonstrate that the unique skills of a professional therapist are required to
safely and effectively provide treatment, that the services can be safely and effectively performed only by a
therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program,
and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design
and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 14 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 additional physical therapy visits (97110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that because of your condition it is hard to get accurate readings while finger stick testing. The Plan denied your request. The Plan says criteria is not met for a CGM.
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 looked at the file and Medicare rules. The record shows you are not insulin treated three or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with Single Power
Option and attachments for the enrollee.
You asked the Plan to pre-approve these services. You say that post-polior suffers from post polio syndrome
and is unable to walk. The Plan denied your request. The Plan says that they cannot approve this power
wheelchair because the requested power seat function is exclusively for the power seat elevation which is a
non-covered service.
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC with Single Power Option is
covered if the beneficiary requires a drive control interface other than a hand or chin-operated standard
proportional or the beneficiary meets coverage criteria for a power tilt or a power recline seating system and
the system is being used on the wheelchair.
We looked at the file and Medicare rules. The file does not indicate that a drive control interface other than a
hand or chin-operated standard proportional joystick or that a power tilt or power recline seating system are
being requested. 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 a Group 3 power wheelchair
(PWC) with Single Power Option and attachments for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a KneeRover knee scooter to be provided by an out of network provider.
You asked the Plan to pre-approve a KneeRover knee scooter. You say that a KneeRover knee scooter is more convenient and safe for you to use indoor and outdoor. The Plan denied your request. The Plan says there are in-network providers of knee scooters. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a KneeRover knee scooter to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like to see this provider because you used them before. The Plan denied your request. The Plan says there are in-network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like approval to see this physician. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a static progressive stretch knee device (E1811). You asked the Plan to pre-approve a static progressive stretch knee device. You say that the doctor has prescribed this device because the enrollee is lacking range of motion in the left knee and you are requesting an in-network exception as the sole provider. The Plan denied your request. The Plan says this device is considered experimental, investigational or unproven for any indication and therefore not covered. Enrollee's must receive their medical services from an in-network provider.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a static progressive stretch knee device have not been met. Therefore, we decided that the Plan does not have to pre-approve a static progressive stretch knee device (E1811).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a colonoscopy and biopsy with monitored anesthesia care.
You asked the Plan to pre-approve a colonoscopy and biopsy with monitored anesthesia care. 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 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 a colonoscopy and biopsy with
monitored anesthesia care. Our reviewer says that the requested items/services are considered medically
reasonable and necessary in this case. Our physician reviewer found the documentation supports that you have
"a tortuous colon and coming out of sedation too early during first colonoscopy in 2009." The 2009 colon exam
accordingly was incomplete due to your pain, necessitating a completion barium enema. Therefore, you meet
criteria for the requested MAC sedation due to history of, anticipated, intolerance to conscious sedation and
prolonged endoscopic procedure (both EGD and colonoscopy are planned at the same sitting).
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 colonoscopy and biopsy with monitored anesthesia care have been met.
Therefore, we decided that the Plan has to pre-approve a colonoscopy and biopsy with monitored anesthesia
care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional eight physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of documentation that the unique skills of a therapist are necessary for this treatment plan. 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 additional visits. Our reviewer says that the requested additional visits are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested additional therapy is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy per documentation and is able to train at a health club several times weekly. The enrollee has no weakness and walks without assistive device. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee should be able to transition to a home exercise program to continue work on flexibility. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional eight physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you cannot move your legs and need to be able to sit in a chair while showering. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. The Plan denied your request. The Plan says
that this is statutorily non-covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve
a power seat elevation feature (E2300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve an outpatient surgery. You say that you would like approval to perform
these services to this member. The Plan denied your request. The Plan says there are in-network providers
available for these services.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an outpatient surgery to be provided by an out of network (OON) provider.