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

We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle.
You asked the Plan to pre-approve a Group 1 standard power operated vehicle. You say that you need to take the POV in your car to use at other locations indoors. The Plan denied your request. The Plan says criteria for a POV have not been met.
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 does not show that you do have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or you can safely operate the PMD being requested. 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 PMDs for use only outside the home. 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 Group 1 standard power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery and related services provided on July 22, 2019.
You asked the Plan to waive the coinsurance for outpatient surgery and related services. You say that you should not have to pay this much for surgery you chose to have out-of-network. The Plan denied your request. The Plan says the out-of-network coinsurance 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 30% coinsurance per visit for out-of-network outpatient surgery, 30% coinsurance for out-of-network Medicare-covered supplies and 30% coinsurance for each out-of-network Medicare-covered Part B drug.
You have been asked to pay a total of $1,102.73 for the outpatient surgery and related services.
Service
Allowed Amount
Standard Coinsurance
Member Liability
Cataract Removal
$2,254.46
30%
$676.34
Posterior Intraocular Lens
$247.28
30%
$74.18
Anesthesia for Lens Surgery
$66.72
30%
$20.02
Anesthesia for Lens Surgery
$66.72
30%
$20.02
Anesthesia
$189.65
30%
$56.90
Medical Supplies
$530.45
30%
$159.14
Pharmacy
$302.46
30%
$90.75
Saline Infusion
$9.16
30%
$2.75
Propofol Injection
$3.16
30%
$0.95
Lidocaine Injection
$4.21
30%
$1.26
Unclassified Drug Injection
$0.81
30%
$0.24
Midazolam Hydrochloride Injection
$0.61
30%
$0.18
TOTAL:
$1,102.73
The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical supplies fall within the "Outpatient hospital care" benefit category. The Part B drugs fall within the "Medicare Part B prescription drugs" 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 outpatient surgery and related services provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit for the evaluation and management of an established patient (99337) provided on September 11, 2019 by out of network provider.
You asked the Plan to pay for a rest home visit. You say that you were called in by the facility therefore, there was a medical necessity pre-established with the patient and the facility. You say you have enclosed supporting medical records to prove the need for services rendered to be paid to the provider of the service. The Plan denied your request. The Plan says Collaborative Geriatrics is a non-contracted provider. The Plan says that a review of the enrollee's account shows she did not have a valid referral on file for the service in question. The Plan further says that they do not deny the medical necessity of the services however, authorization was not obtained. In addition, the enrollee's services were not urgent or emergent in nature.
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 a domiciliary or rest home visit for the evaluation and management of an established patient (99337) provided on September 11, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee by the doctor on October 31, 2018.
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 procedure code 95999 is 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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was performed and there is a more appropriate code for these services. 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 pay for the services rendered to the enrollee by the doctor on October 31, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that over the counter compression stockings do not work and your doctor recommended zippered compression stockings. The Plan denied your request. The Plan says you do not have leg wounds.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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. Our physician reviewer found the enrollee underwent coronary bypass surgery, which was complicated by peripheral arterial disease/peripheral vascular disease and a groin infection. The enrollee continues to receive wound care and antibiotics. The enrollee is not intubated/ventilated. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided on February 11, 2019.
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request. The Plan denied your request. The Plan says you received emergency care services on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan.
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 $90 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The case file shows that you received emergency room services on February 11, 2019. You have been asked to pay a $90 copayment for the emergency room services. The emergency room services fall within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room services provided on February 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on August 24, 2018 by out of network provider.
You asked the Plan to pay for subsequent nursing facility care. You say that you were assigned this patient at the facility and you are not aware of the patient's insurance and accepted the responsibility to care for the patient. The Plan denied your request. The Plan says the doctor is not a participating provider with the Plan. The Plan says that in most cases care you receive from an out-of-network provider will not be covered.
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 subsequent nursing facility care (99308) provided on August 24, 2018 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 6, 2019,
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for this copayment because you went in to have something corrected from a previous 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 each specialist visit for Medicare-covered services. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a scheduled follow-up appointment.
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 specialist office visit provided on August 6, 2019,
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Emgality pen for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee has tried several medication with therapeutic failure. The Plan denied your request. The Plan says that this is not covered under Part B.
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 the Emgality pen for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 you need inserts because you have pain when you walk. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on July 1, 2019.You asked the Plan to pay for perfusionist services (99190). You say that the Plan should pay this claim.The Plan denied your request. The Plan says Medicare does not pay any provider or supplier other than the hospital for services furnished to the enrollee while an inpatient in the hospital.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and neededfor use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the service was in ahospital.Payment for this service would have been included under the global facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay forassembly and operation of pump with oxygenator or heat exchanger provided on July 1, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite provided on September 16, 2019.You asked the Plan to pay forthe resin-based composite. You say that you were not informed that this provider was out-of-network with your plan.The Plan denied your request. The Plan says this provider is an out-of-network provider with your plan. The Plan also says that you do not have benefits to see out-of-network providers.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe resin-based composite provided on September 16, 2019.Your complaint about being responsible for this bill after not being informed that this provider was out-of-networkis 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 physician's services provided on July 12, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospitalization from January 11, 2020.You asked the Plan to pre-approvethe inpatient psychiatric hospitalization. You say that the member is not stable for discharge.The Plan denied your request. The Plan says as of January 11, 2020, the member is no longer a danger to themselves or others.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospitalization. Our reviewer says that this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. Our physician reviewer found it did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the member's condition or for the purpose of diagnosis beyond the date in question.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 inpatient psychiatric hospitalization have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient psychiatric hospitalization from January 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2740), core buildup (D2950), and the root canal (D3330).You asked the Plan to pre-approvethe dental services. You say that you have sleep apnea. You say that you have an oral device for when you sleep. You say that due to the pressure on your jaw,  your tooth has been damaged.The Plan denied your request. The Plan says the requested services are not listed as covered services.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 services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea crown (D2740), core buildup (D2950), and the root canal (D3330).
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 you have worn custom orthotics for a long time in order to function normally. You say that the requested orthotics are for your various back issues. Without the orthotics, you say that you will not be able to function.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger services provided on August 13, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger services. You say that you would like the plan to reconsidertheir denial.The Plan denied your request. The Plan says the services billed are not payable.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 99190 is Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour.We find that CPT code 99190 is not supported in the medical record. Specifically, these services were provided while the enrollee was inpatient. Payment for this service would be included in the DRG payment to the facility. Payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger services provided on August 13, 2019.