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

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 5,
2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary for
the enrollee. The Plan denied your request. The Plan says the record does not demonstrate the prescribing
physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed in the
Medicare rules section.
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 lumbar-sacral orthosis. Our reviewer
says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found an
appropriate history and a physical examination of the back would reasonably be required to adequately assess
whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support
that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is
insufficient documentation of an appropriate evaluation and a credible physical examination of the back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit.

You asked the Plan to waive the copayment for the ER visits. You say that the first hospital was not able to do anything for you and referred you to another ER. You say that you should not have a copayment for each facility. The Plan denied your request. The Plan says the copayments applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment per emergency department visit.

You have been asked to pay a $90 copayment for each ER visit. The total amount you owe is $180 ($90/visit x 2 visits = $180). The ER visits fall within the "Emergency care" benefit category. The records show that you were treated in the ER at each facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are therefore adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.
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 accessories. 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 need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control.
The enrollee's strength and function in the upper extremities with the ability to feed himself indicates that the patient can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests.

You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the increase in charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 laboratory services provided in an outpatient hospital facility.

You have been asked to pay the allowed amount of $19.80, which is less than the $40 copayment for laboratory tests. Laboratory tests fall 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 laboratory tests.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee's needs are custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's
condition. The enrollee's care needs at this point, as a practical matter, can be provided at a lower level of care
(ex. home, AL, LTC).
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided by an opted-out provider.

You asked the Plan to pay for office visits. You say that you were told that in-network or out-of-network services would be reimbursed and were never informed about a privately contracted provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of Medicare coverage and is not eligible for payment.

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 office visits provided by an opted-out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Transcutaneous Electric Nerve Stimulation (TENS) units and garment provided January 30, 2020, to May 30, 2020.
You asked the Plan to pay for the TENS units and garments. You say that this service was medically necessary. The Plan denied your request. The Plan says the TENS unit is not covered in this case.
The Plan follows Medicare rules. Medicare rules say that a TENS unit is subject to the criteria listed in the Medicare rules section. 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 TENS units and garments. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found the enrollee is a 49-year-old man with chronic neck pain. Based on Medicare criteria, TENS is not a covered benefit for neck pain. Therefore, the request is considered not medically reasonable or 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 TENS units and garments have not been met. Therefore, we decided that the Plan does not have to pay for the Transcutaneous Electric Nerve Stimulation (TENS) units and garment provided January 30, 2020, to May 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for lab services you received from an outpatient hospital facility.

You asked the Plan to reduce the copayment for the lab services. You say that you believe you should only have to pay a $10 copayment for these lab services. 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 $40 copayment for lab services at an outpatient hospital facility.

You have been asked to pay a $40 copayment for the lab services. The facility that provided these lab services is considered part of an outpatient hospital facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for lab services you received from an outpatient hospital facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral periapical
radiographic images (D0220) provided from June 4, 2020, through July 8, 2020.
You asked the Plan to pay for a limited oral evaluation and intraoral periapical radiographic images. You say
that you would like reimbursement for these services. The Plan denied your request. The Plan says the provider
is out-of-network.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a limited oral evaluation and intraoral periapical radiographic images have not been met.
Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has
contracted providers available to provide these 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 a limited oral evaluation
(D0140) and intraoral periapical radiographic images (D0220) provided from June 4, 2020, through July 8,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination of Vervoy and Opdivo for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this combination does not meet off-label requirements.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Nivolumab and ipilumumab is indicated for patients with soft tissue sarcoma who have failed standard chemotherapies and have had no prior immunotherapy. The combination is not FDA approved or supported for off-label use in major drug compendia or the medical literature after progression on prior immunotherapy. The enrollee has progressed on prior immunotherapy. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve a combination of Vervoy and Opdivo for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140).

You asked the Plan to pay for the limited oral exam. You say that the services should be covered. The Plan denied your request. The Plan says 2 oral exams per 1 calendar year are covered. The Plan says that the frequency limit has been exceeded. The Plan also says that the oral exams that you received were paid.

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 frequency limit of 2 oral exams per calendar has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140).
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 care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee is an 87-year-old female with
cerebrovascular accident currently in an inpatient rehabilitation facility.
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 care 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the irrigation and debridement services provided on October
16, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is
another code that is appropriate for the documented procedure.
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 25115 is radical excision of bursa, synovia of wrist, or
forearm tendon sheaths (e.g., tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors.
The CPT Code Manual definition of code 26145 is Synovectomy, tendon sheath, radical (tenosynovectomy),
flexor tendon, palm and/or finger, each tendon.
The records show that the enrollee received right arm irrigation and debridement. We find that CPT codes
25115 and 26145 are not supported in the medical record. Based on the information provided, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for
the irrigation and debridement services provided on October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397) provided September 29, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says there was no evidence of an established relationship between the ordering physician and the member.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section. 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 knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically necessary and reasonable. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397) provided September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace (L0648) provided August 20, 2020.
You asked the Plan to pay for the back brace. You say that this item was medically necessary. The Plan denied
your request. The Plan says there is a lack of supporting information in the medical records to support the
codes billed.
The Plan must follow Medicare rules. Medicare rules say that a durable medical equipment provider is not
eligible for reimbursement when the enrollee is contacted by a phone call without receiving written permission.
We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via
an unsolicited phone call regarding the provision of the item at issue. Based on this information, we decided
that Medicare rules for coverage of the back brace have not been met. Therefore, we decided that the Plan does
not have to pay for the back brace (L0648) provided August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating hospital.

You asked the Plan to waive the copayment for lab work. You say that you get your lab work done at the same building as your doctor. You say that you think you are being overcharged. The Plan denied your request. The Plan says the correct copayment has been applied to the services that were provided.

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 outpatient diagnostic tests/laboratory test/outpatient hospital facility.

You have been asked to pay a $40 copayment for lab work. The correct copayment has been applied to the services that were provided. Lab work falls within the outpatient diagnostic tests/laboratory test/outpatient hospital facility 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 lab work provided by a participating hospital.