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

We decided that the Plan does not have to pay for laboratory services provided on September 23, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for laboratory services provided on September 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (C1821, 22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (C1821, 22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network durable medical equipment purchased on January 14, 2021.
You asked the Plan to pay for out of network equipment. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization and this equipment was purchased out of network.
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 Plan contract states durable medical equipment requires prior authorization. The provider in this case is not a network provider with the Plan. The Plan did not pre-approve this equipment. We found no exception that would require the Plan to pay for this equipment. Therefore, we decided that the Plan does not have to pay for out of network durable medical equipment purchased on January 14, 2021 from Alpine Home Medical Equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen equipment you rented from January 21, 2021, to May 21, 2021.

You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you were never told that you would have to pay anything for this equipment. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. 

You have been asked to pay 20% coinsurance for the oxygen equipment. The oxygen equipment falls within the durable medical equipment 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 coinsurance for oxygen equipment you rented from January 21, 2021, to May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insulin pump supplies and sensor you received on September 8, 2020.
You asked the Plan to waive the coinsurance for the insulin pump supplies and sensor. You say that you have never had to pay coinsurance for these items in the past. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for items $500 or more for durable medical equipment and related supplies. Records show that you received multiple diabetic supplies on September 8, 2020. Two of the items you received (represented by item codes A4224 and A9276) have an allowed amount of over $500. You have been
asked to pay 20% coinsurance for these two items. These items fall within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the insulin pump supplies and sensor you received on September 8, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your physician prescribed orthotics because the great pain you have when walking. 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-approve foot orthotics
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no clinical advantage of an LTACH over an acute hospital.
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. The ernollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (83036) provided on April 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (83036) provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that it will allow you to check your blood glucose more often. The Plan denied your request. The Plan says the criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin. 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 continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for physical and occupational therapy for the enrollee.
You asked the Plan to provide coverage for physical and occupational therapy for the enrollee. You say that this treatment will improve the enrollee's ability to assist with daily activities as the enrollee is a resident in a skilled facility. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 provide coverage for these services. 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 additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and 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 by or under the supervision of a therapist. There has been caregiver and enrollee instruction on safety, body mechanics, compensatory strategies. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist 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 these services have not been met. Therefore, we decided that the Plan does not have to provide coverage for physical and occupational therapy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital observation services you received from March 22, 2021, to March 23, 2021.
You asked the Plan to waive the copayment for the hospital observation services. You say that you went to the emergency room via ambulance. You stated that you were only in the emergency room, so only the emergency room copayment should apply. The Plan denied your request. The Plan says you were charged this copayment 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 $195 copayment for outpatient hospital observation services.
The medical records show that you went to the emergency room at 9:30pm on March 22, 2021. After you were evaluated in the emergency room, the doctor there signed an order to admit you to observation at 12:14am on March 23, 2021. You remained in observation care until your discharge at 8:52am on March 23, 2021. You have been asked to pay a $195 copayment for the hospital observation services. 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 hospital observation services you received from March 22, 2021, to March 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional transportation trips (A0120).
You asked the Plan to pre-approve the additional transportation trips. You say that the additional trips are medically necessary. The Plan denied your request. The Plan says the transportation benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. The records show you have already used 60 one-way trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 60 additional transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0480) provided on March 31, 2021, by
an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that the services were medically necessary. The Plan
denied your request. The Plan says services were provided 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. The records provided for review do not show that the services at issue were urgent or
emergent. 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 drug testing (80307, G0480) provided on March 31, 2021, by an
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the spinal procedure. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.
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 spinal procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process devices remain experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spinal procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on March 1, 2021.

You asked the Plan to pay for moderate sedation services (99153). You say that the procedure was rendered in an appropriate place of service. The Plan denied your request. The Plan says this procedure code is a Technical component only code and was billed and paid under the hospital claim.

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 99153 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; each additional 15 minutes intraservice time (List separately in addition to code for primary service).

We find that CPT code 99153 is not payable as billed. Specifically, code 99153 is a Technical Component Only code. When billed in a facility setting it is not payable to the physician but may be paid to the facility. Based on this information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontics (D6240) and retainer crowns (D6750) provided
on February 8, 2021.
You asked the Plan to pay for the pontics (D6240) and retainer crowns (D6750). You say that the dentist you
visited is now listed as an out-of-network provider. You say that you were never informed the dentist is no
longer in-network which is why you continued to see this provider. The Plan denied your request. The Plan
says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
pontics (D6240) and retainer crowns (D6750) provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for repair cast partial framework upper (D5622) provided on April 2, 2021.
You asked the Plan to pay for repair cast partial framework upper. You say that you cannot afford to pay for this service. The Plan denied your request. The Plan says the services at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for repair cast partial framework upper (D5622) provided on April 2, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an opt-out provider provided on March 30, 2021.
You asked the Plan to pay for the dental services provided by an opt-out provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not payable when provided by a provider that has opted out of the Medicare program.
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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services provided by an opt-out provider provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device and appliances provided on February 9, 2021.
You asked the Plan to pay for a pneumatic compression device (E0675) and appliances (E0673). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included in the facility payment.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and appliances provided on February 9, 2021.