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

We decided that the Plan does not have to waive the coinsurance for the intravitreal eye injection provided on January 30, 2020.
You asked the Plan to waive the coinsurance for the intravitreal eye injection. You say that the Evidence of Coverage states that prescription drug claims that are classified as Part B services will be covered at 100% if billed in conjunction with an office visit copayment. 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 10% coinsurance for Medicare-covered surgery or other services at an in-network outpatient hospital or in-network ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $11.12 which is 10% of the allowed amount for the intravitreal eye injection. The allowed amount is $111.18. ($111.18 x 10% = $11.12). The intravitreal eye injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the intravitreal eye injection is considered a surgical procedure which was received at an outpatient facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the intravitreal eye injection provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services provided from December 3, 2019 to December 20, 2019 and billed under codes 99203 and 97110.You asked the Plan to pay forchiropractic services. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says while a portion of this claim was paid, services billed under codes 99203 and 97110 are not related to manual manipulation of the spine and are not covered by Medicare.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 codes denied were done so appropriately as they are not related to manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay forchiropractic services provided from December 3, 2019 to December 20, 2019 and billed under codes 99203 and 97110.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction rendered on February 26, 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.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one routine eye refraction per year. We looked at the file and the Plan's rules. The file shows that you received an eye refraction on February 26, 2020. You previously had a routine eye refraction on February 6, 2020 for which the Plan approved and paid. The Plan covers only one routine eye refraction per year. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction rendered on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe brand specific urological supplies.You asked the Plan to pre-approvethe brand specific urological supplies. You say that you want this brand of external catheter system.The Plan denied your request. The Plan says this brand is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.We looked at the file and Medicare rules. There is no documentation why a standard external urine catheter system and supplies cannot be used. This brand is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the brand specific urological supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvethe brand specific urological supplies
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency medicine services (CPT 10061) provided to the enrollee on September 17, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 10061 (1 unit) remains not supported.
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 10061 is "Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found there is no documentation of an incision and drainage on the date of service in this case. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for emergency medicine services (CPT 10061) provided to the enrollee on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bedside rails, toilet rail, lightweight wheelchair, wound care supplies, commode chair, and oximeter device purchased from December 21, 2019 to February 9, 2020.
You asked the Plan to reimburse you for the bedside rails, toilet rail, lightweight wheelchair, wound care supplies, commode chair, and oximeter device. You say that you needed these items. The Plan denied your request. The Plan says oximeters are not covered and the Plan has network providers available for the remaining items.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Durable medical equipment purchased privately through the internet, or by private purchase are not eligible for coverage by your Medicare governed health plan. Oximeters are statutorily not covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the bedside rails, toilet rail, lightweight wheelchair, wound care supplies, commode chair, and oximeter device purchased from December 21, 2019 to February 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 23 skilled nursing visits.
You asked the Plan to pre-approve 23 skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 23 skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that ongoing skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration beyond what was approved by the health plan. You have had extensive instruction and prior skilled nursing (SN) visits. Your wounds are not complex and do not require ongoing skilled nursing level care beyond what was already approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 23 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 23 skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 30, 2019 by a non-network provider.
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 were rendered by a non-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 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 August 30, 2019 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator.
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that you would like the plan
to reconsider their denial The Plan denied your request. The Plan says the requested device is not medically
necessary.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs
separated by a minimum of 90 days.
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 an ultrasonic osteogenesis stimulator.
Our reviewer says that the documentation does not support that the requested device is medically reasonable or
necessary. Our physician reviewer found the enrollee was placed in a CAM walker and told to continue nonweight
bearing status. It is well documented that the enrollee's fracture of the first metatarsal left side was
caused by trauma on May 28, 2020. Criteria for authorization of a bone growth stimulator requires a diagnosis
of the nonunion which is established by no healing of bone on x-rays separated by 90 days. The enrollee to date
has had the traumatic fracture for only three weeks. Therefore, a nonunion has not been established. Therefore,
the enrollee does not meet criteria for the requested 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 an ultrasonic osteogenesis stimulator have not been met. Therefore, we decided
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you are a type 1 diabetic and on the dates of service you experienced severe blood sugar drops where help was required to bring your sugar levels back up to normal. You say that fortunately you did not require hospitalization or ambulance transport which saved Medicare additional expenses. You stated that you absolutely required the assistance provided by the ambulance responders on the dates of service. You asked the Plan to reconsider their denial and provide coverage.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 13, 2019 and February 4, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Zilretta injection.
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 the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knees. Zilretta was administered in July of 2019. The safety and efficacy of a repeat injection is not demonstrated. The repeat injection is not reasonable or medically necessary for the 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat Zilretta injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring System.You asked the Plan to pre-approvea continuous glucose monitor. You say that you are being denied a system that can save your life.The Plan denied your request. The Plan says there is no documentation that you use insulin or an insulin pump. 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. You are not insulin treated so you do not meet the Medicare coverage criteria for a CGM. 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-approvea FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on December 2, 2019, December 30, 2019 and January 13, 2020.You asked the Plan to waive the copayment for wound debridement. You say that you weren't informed you would be charged twice for the same procedure. You say that you cannot afford the extra charge.The Plan denied your request. The Plan says the copayments 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 $400 copayment per date of service for an outpatient hospital facility visit and a $20 copayment per provider, per date of service for outpatient rehabilitation services.You have been asked to pay a total of $544.58 for wound debridement. The wound debridement provided on December 2, 2019 and December 30, 2019 falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The wound debridement provided on January 13, 2020 falls within the "Outpatient rehabilitation 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 wound debridement provided on December 2, 2019, December 30, 2019 and January 13, 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 for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services you need in other settings.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. The patient was medically stable with no evidence of need for supervision by physical medicine and rehab physician or need for acute rehab nursing care. Functionally given her current level of function, it is unrealistic to predict in 7-10 days she will make any significant functional recovery to justify IRF admission. The patient may benefit from further physical therapy and an occupational therapy but does not require an intensive therapy program. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services (92015) provided on January 30, 2020.
You asked the Plan to pay for the vision services. You say that you were told to see an eye doctor for an exam of your cataracts. You cannot go a participating provider, because it is more than 150 miles from you and this provider is 21 miles away The Plan denied your request. The Plan says eye refractions are only covered if performed by a participating provider and performed as a routine screening.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed by a participating provider and performed as a routine screening.
We looked at the file and the Plan's rules. Refractions are only covered when performed by a participating provider and performed as a routine screening. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for eye refraction services (92015) provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the enrollee has foot pain and needs orthotics.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 pre-approvefoot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on August 6, 2019.
You asked the Plan to pay for the chest x-ray. You say that per CMS, you are not allowed to bill globally. The Plan denied your request. The Plan says the providers that rendered the professional and technical components of this service have the same TIN and this code should be billed globally.
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 71046-26 is not supported in the record. Specifically, the record indicates that the provider rendered both the professional and technical components of this service. This means that CPT code 71046-26 should be billed globally and not with modifier 26. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided on August 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil 100mg tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy with the plan.
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 requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Modafinil 100mg tablet for the enrollee.