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

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on May 13, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on May 13, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography Angiography (CTA) of the Chest (71275).
You asked the Plan to pre-approve the CTA of the chest. You say that the service is medically necessary. The
Plan denied your request. The Plan says that coverage criteria was not met.
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 the CTA of the chest. Our reviewer
says that the requested procedure is medically necessary. Our physician reviewer found the enrollee is noted to
have undergone a TAA repair in 2010. In this case, it appears that the enrollee has not had thoracic imaging
since 2017. New imaging would be reasonable and necessary.
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 CTA of the chest have been met. Therefore, we decided that the Plan has to
pre-approve Computed Tomography Angiography (CTA) of the Chest (71275).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on November 19, 2019.You asked the Plan to waive the copayment for the x-ray. You say that you cannot afford to pay this amount. You say this is a lot of money for you. 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 $30 copayment for each Medicare-covered test. You have been asked to pay a $30 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the x-ray provided on November 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the admission to the SNF provided by from November 1, 2019 to November 11, 2019.
You asked the Plan to pay for the SNF admission. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee was not approved for admission to the skilled nursing facility. The Plan also says that the enrollee did not need skilled medical care or skilled nursing care.
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 pay for the SNF admission. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pay for the admission to the SNF provided by from November 1, 2019 to November 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 1, 2019 to October 29, 2019.You asked the Plan to pay forhome health 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 were not billed correctly.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an invalid type of bill code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 1, 2019 to October 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from September 2, 2019 to
September 30, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home
health services under a plan of treatment.
We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid TOB code.
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 home health services rendered from September
2, 2019 to September 30, 2019.
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 on the date of service you were in a hotel in city visiting your family. You say that you are diabetic and you realized you had not taken your insulin. You stated that you took the wrong dosage of insulin and quickly began sweating and became incoherent. You woke your wife and she called for emergency medical services. The responder assessed and immediately treated you. You say that the EMS responders saved your life from insulin shock. After you had recovered, the responders asked you if you needed to be transported. You say that you declined transportation because you felt fine. You say that the EMS responders performed lifesaving services for you and there was no need to go to the hospital at that time.The Plan denied your request. ThePlan 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 August 19, 2019. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from December 4, 2019 to December 9, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as the inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says that the 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 the inpatient hospital care provided December 4, 2019 to December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea replacement power wheelchair (K0861) and accessories (E2300, E2359, E1007, E2311, E1012, E1028, E2377, E2313, E2622, E1028, E2620, E0956, E0955).You asked the Plan to pre-approvea replacement power wheelchair and accessories. You say that the enrollee cannot afford repairs on her current chair.The Plan denied your request. The Plan says the enrollee's current chair is less than five years old. The Plan does not have any cases for repairs on this chair.The Plan must follow Medicare rules. Medicare rules say that replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment.  If the item of equipment has been in continuous use by the patient on either a rental or purchase basis for the equipment's useful lifetime, the beneficiary may elect to obtain a new piece of equipment. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years.We looked at the file and Medicare rules. The record shows that the enrollee previously received a power wheelchair in 2016. As it is less than five years old, the reasonable useful lifetime requirement has not been met. Based on this information, we decided that Medicare rules for coverage of a replacement power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approvea replacement power wheelchair (K0861) and accessories (E2300, E2359, E1007, E2311, E1012, E1028, E2377, E2313, E2622, E1028, E2620, E0956, E0955).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
You asked the Plan to pre-approve the endoscopy. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted documentation did not indicate a diagnosis of unexplained blood loss, Celiac disease, or Crohn's disease - all of which are medically necessary for this request.
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 endoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the criteria for wireless capsule endoscopy or SmartPill. Relative to SmartPill, gastroparesis has already been well documented by nuclear medicine gastric emptying testing. Available records further document "moving bowels daily; patient states he will not go through with another colonoscopy in the future" (per 3/5/2020 office charting on page 28 of 60). Accordingly, available records do not at this time support the medical necessity of assessment of distal gut transit by SmartPill. 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 endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable gaseous oxygen system, oxygen concentrator and ventilator for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that the request for oxygen and for the ventilator are denied until such time the enrollee has a face to face visit to clarify your current clinical status and ongoing need for oxygen and ventilator.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 these services are not medically reasonable and necessary for the enrollee in this case. The enrollee has a diagnosis of COPD. Per the documentation provided the enrollee has been prescribed home oxygen and a trilogy ventilator but has been consistently noncompliant. Per the pulmonary documentation from the visit on 10/19 the room air O2 sat was 95% and there were no reported downloads to assess O2 from the Trilogy ventilator. Per the notation the enrollee again was noted to be noncompliant with O2/Trilogy ventilator. This patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable gaseous oxygen system, oxygen concentrator and ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on November 6, 2019.
You asked the Plan to waive the copayment for the outpatient clinic visit. You say that you should be billed as a primary office visit instead of as an outpatient 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 $50 copayment for outpatient hospital services. You have been asked to pay a $50 copayment for the outpatient clinic visit. The outpatient clinic visit falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on June 17, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that this was a follow up appointment. You say that this should have been covered. The Plan denied your request. The Plan says the claim reprocessed to apply a $35 copayment.
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 $35 copayment for all other in-network, Medicare-covered eye exams. You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up. 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 eye exam provided on June 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
October 27, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you are disputing the
unpaid charges for the emergency room 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $90 copayment for emergency services at an in-network emergency room.
The enrollee has been asked to pay a $90 copayment for the emergency room visit. The emergency room visit
falls within the "Emergency care" benefit category. This means that the enrollee has been asked to pay the
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the emergency room visit provided on October 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck/spine (72141). You asked the Plan to pre-approve an MRI of the neck spine. You say that the service is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the neck spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no discussion concerning the reason for a repeat of the cervical spine MRI which had been done less than 1 month ago. If there is clinical concern for cord ischemia leading to myelomalacia and edema it is not addressed in the provided records. 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 MRI of the neck spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck/spine (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on October 23, 2019. 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 codes 64493, 64494, and 64495 are 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 64493 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level. The definition of code 64494 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure). The definition of code 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure). We find that CPT codes 64493, 64494, and 64495 are not supported in the medical record. Specifically, there is no documentation of a diagnostic injection to the paravertebral facet joint with fluoroscopic guidance to support primary procedure code 64493. Given that the primary code is not supported, add on codes 64494 and 64495 are also not supported. 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 injection services rendered on October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion Vertiflex procedure.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support that this device is as safe and effective as the gold standard of decompression.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is considered experimental. More research is needed. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion Vertiflex procedure.