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

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that you need this for inside your room. The 
Plan denied your request. The Plan says you are not able to operate a manual wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules also state that a manual wheelchair for use inside the home is covered if 
the beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to 
safely self-propel the manual wheelchair that is provided in the home during a typical day or has a caregiver 
who is available, willing, and able to provide assistance with the wheelchair. 
 
The record shows that you do not have sufficient upper extremity function and other physical and mental 
capabilities needed to safely self-propel a manual wheelchair. The file also shows that you have a power 
wheelchair. A power wheelchair serves the same purpose as a manual wheelchair. Therefore, we decided that 
the Plan does not have to pre-approve a manual wheelchair (K0001).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the apicoectomy (D3421) provided on June 15, 2020.
You asked the Plan to reimburse you for the dental service. You say that you were told it needed to be cleaned to prevent infection in your sinuses. You say that it was unknown if the service would be covered in full or partially by insurance. You say the you were not told the cost would be so high. You also say that you were not given a chance to evaluate an alternative method or even seek a second opinion. The Plan denied your request. The Plan says the apicoectomy is not listed as a covered service. The Plan says any services not listed are not covered.
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 reimburse you for the apicoectomy (D3421) provided on June 15, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomographic angiography (CTA) of the abdomen and pelvis.
You asked the Plan to pre-approve a CGA. 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 CT scans are covered only when they are 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 CGA. Our reviewer says that the documentation supports that the requested CGA is medically reasonable and necessary. Our physician reviewer found you have been diagnosed with a thoracic aortic aneurysm, a potentially life threatening condition. A CT angiogram has been ordered to characterize the lesion better. CT angiography is indicated for evaluation of this life threatening condition that may require high risk surgical intervention. Therefore, you meet criteria for the requested 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 a CGA have been met. Therefore, we decided that the Plan has to pre-approve computed tomographic angiography (CTA) of the abdomen and pelvis.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the pin retention provided on July 23, 2020. 
 
You asked the Plan to pay for the pin retention. You say that you do not understand why a crown is paid for, 
but the pin retention is not. The Plan denied your request. The Plan says that the pin retention is not covered. 
 
Medicare rules say that a contract provider is an agent of the Plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
Medicare rules also say that the health plan must provide you with a clear and accurate description of the 
Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including 
applicable conditions and limitations and any other conditions associated with the use or receipt of the 
benefits.The Plan follows these rules. 
 
You were referred for the pin retention by a contract provider. The file does not show that the Plan provided 
notice that the pin retention would not be covered. The EOC lists crowns as a covered benefit. You reasonably 
believed that the pin retention would be covered because crowns are covered. Under Medicare rules, this means 
the pin retention is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the pin 
retention provided on July 23, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 30, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan hasto pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.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 careand pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on June 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you have COVID-19. You received oral
and topical medications. You had stable vital signs. You required contact guard assistance with functional
mobility including walking to 100 feet with a rolling walker. You required varying assistance with activities of
daily living. The documentation does not support that you require the specialized skills, knowledge, or
judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically
necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy
services are required on a daily basis. As a practical matter, you do not require the necessary services on an
inpatient basis, at a SNF level of 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 SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory testing provided on February 3, 2020.You asked the Plan to pay forthe laboratory testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The laboratory testing 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 forthe laboratory testing provided on February 3, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluorodeoxyglucose f-18 fdg, diagnostic, per study dose,
up to 45 millicuries (A9552) and positron emission tomography (PET) with concurrently acquired computed
tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh
(78815) provided on May 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries and
PET image with CT skull-thigh. You say that the services were medically necessary. The Plan denied your
request. The Plan says prior authorization must be obtained for non-emergent services rendered by out-of-network
provider.
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 fluorodeoxyglucose f-18 fdg, diagnostic, per
study dose, up to 45 millicuries (A9552) and positron emission tomography (PET) with concurrently acquired
computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to midthigh
(78815) provided on May 27, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 13, 2020, to June 16, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the claim was originally filed to Medicare. The Plan denied your request. The Plan says that this was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented with fever, altered mental status, and an abnormal renal ultrasound. Inpatient admission was appropriate and it was reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 13, 2020, to June 16, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction of benign lesions (17110) and tangential biopsy skin lesion (11102) provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for destruction of benign lesions and tangential biopsy of skin lesion. You say that you were told the service would be covered. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 destruction of benign lesions (17110) and tangential biopsy skin lesion (11102) provided on September 24, 2019 by an out of network (OON) provider.
Your complaint about potentially being told the provider was in-network and the service would be covered is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician telephone patient service (99442) provided on June 11, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the physician telephone patient service. You say that the services provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.
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 physician telephone patient service (99442) provided on June 11, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 18, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. 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 physician's services provided on August 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve the spine surgery. You say that please allow a referral to see an out of
network surgeon because you are living with unbelievable pain and cannot tie your shoes or bend, sit or walk.
You have been denied many times for no reason. The Plan denied your request. The Plan says enrollee's must
receive their medical services from an in-network provider. If an enrollee requires medical care that Medicare
requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can
receive the care from an out-of-network provider.
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
spine surgery to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 30, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.
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 laboratory services provided on June 30, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99342) and debridement of nails (11721) provided on June 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for home visit and nail debridement. You say that you assumed the primary care physician sent in a referral. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 home visit (99342) and debridement of nails (11721) provided on June 3, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waivethe $480.61 patient responsibility for colorectalcancer diagnostic services provided on August 24, 2020. You asked the Plan to waivethis costshare. You say that you were not told there would be a copayment for each service.The Plan denied your request. The Plan says you had a colonoscopy on October 10, 2019 where a polyp was removed. The Plan states you had another polyp removed on August 26, 2020 that was hyperplastic.   This repeat diagnostic test was recommended to be performed in 6 months.This test wasdiagnostic in nature and was not a screening.  This cost share was charged based on the claim submitted by your provider and the Plan contract agreement. 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 cost share for outpatient surgical or diagnostic services. This testing was not ordered by your provider as a screening. 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 waivethis cost share
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing services coded 95937 provided on October 1, 2019.
You asked the Plan to pay for the neuromuscular junction testing 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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, this code represents neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method. The documentation submitted does not support that this code was performed. The documentation indicates that Train of Four Testing/Monitoring was performed which does not meet guidelines of CPT code 95937. Based on this information, we decided that Medicare rules for coverage of the neuromuscular junction testing services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing services coded 95937 provided on October 1, 2019.