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

We decided that the Plan does not have to pre-approve a lower limb prosthesis vacuum pump.
You asked the Plan to pre-approve addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system (L5781). You say that the vacuum pump has nothing to do with the vertical shock reducing pylon feature. The Plan denied your request. The Plan says the vacuum pump L5781 is a part of code L5988 (Addition to lower limb prosthesis, vertical shock reducing pylon feature) and cannot be billed separately.
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 addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system (L5781). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested orthosis is not not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not reveal evidence on an objective physical examination of skin findings, volume changes in the residual limb, or indications for the need for a volume management system. The requested L5781 exceeds the patient's medical need and is not medically 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 addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system (L5781) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower limb prosthesis vacuum pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program.
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections.
You asked the Plan to pre-approve the requested services. You say that the enrollee has had greater than 80% improvement from the past injection. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that facet injections are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has a history of low back pain. In this case, there is no documentation that she received 80% relief from a previous facet injection, no documentation as to what levels were injected or the duration of pain relief. In addition, the levels injected were 3 joint spaces which exceeds the guidelines at this time. According to guidelines and other accepted studies concerning facet injections, no more than 2 levels should be injected at one time. The review has determined that the records do not show the enrollee meets the coverage criteria for a second injection. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dental restoration provided on April 26, 2021.
You asked the Plan to waive the coinsurance for the resin-based composite - two surfaces, posterior filling. You say that you do not want to pay the coinsurance cost for the resin filling. The Plan denied your request. The Plan says you were charged the coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for Restorations, Amalgam and/or Composite. You have been asked to pay 50% coinsurance for the resin-based composite - two surfaces, posterior filling. Resin-based composite - two surfaces, posterior fillings fall within the Restorations, Amalgam and/or Composite benefit category. Your dentist submitted a claim for this procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for the dental restoration provided on April 26, 2021.
Please note, your complaint is not a valid appeal for medical coverage. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99153) provided on October 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable in the facility setting.

The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting. 

We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the services (99153) provided on October 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99350) provided on June 18, 2020.
You asked the Plan to pay for a home visit. You say that this was medically necessary. The Plan denied your request. The Plan says the billed code is not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that a home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home. We looked at the file and Medicare rules. The records do not show that the physician was present in the beneficiary's home when the service at issue was provided. Based on this information, we decided that Medicare rules for coverage of a home visit have not been met. Therefore, we decided that the Plan does not have to pay for a home visit (99350) provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 21, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 31). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled therapy or skilled nursing services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on February 6, 2021.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.

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.

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a Plan provider. The Plan did not pre-approve the hearing aids. We found no exception that would require the Plan to pay for the hearing aids. Therefore, we decided that the Plan does not have to pay for hearing aids provided by on February 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on April 5, 2021.

You asked the Plan to pay for determination of refractive state (92015). You say that you went for a yearly
exam and decided to have a routine eye exam. The Plan denied your request. The Plan says refraction is not
covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we
decided that the Plan does not have to pay for the refraction provided on April 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient psychiatric hospitalization.
You asked the Plan to pre-approve the inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 the service is not medically necessary. Our physician reviewer found it is not expected this enrollee will improve in a reasonable period of time for the dates in question as they did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. 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. Specifically, the patient was compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. Therefore, we decided that the Plan does not have to pre-approve the inpatient psychiatric hospitalization
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on February 13, 2021.
You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. We looked at the file and Medicare rules. The billed diagnosis code, C18.9, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on February 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Accu-Chek Aviva Plus test strips.
You asked the Plan to pre-approve the Accu-Chek Aviva Plus test strips. You say that this request is medically necessary. The Plan denied your request. The Plan says there is no evidence the Plan's preferred brand test strips would not be sufficient for your condition.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case, we requested additional medical information from the provider to determine if the criteria for coverage have been met. We did not receive additional medical records. Without these medical records, we are unable to determine if the Plan's preferred brand test strips would not be suitable for your condition. Based on this information, we decided that Medicare rules for coverage of the Accu-Chek Aviva Plus test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Accu-Chek Aviva Plus test strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ERCPs provided on November 5, 2020 and December 7, 2020.

You asked the Plan to waive the copayments for the ERCPs. You say that you should not be responsible for the copayments. The Plan denied your request. The Plan says you have been asked to pay 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 $150 copayment for in-network outpatient surgery.

You have been asked to pay a $150 copayment for the ERCPs on each date of service. The ERCPs fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayments for the ERCPs provided on November 5, 2020 and December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on November 13, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Chemical Radiofrequency Ablation (RFA) to the
lumbar spine (64635 and 64636).
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an RFA is covered when the criteria listed in the
Medicare Rules section of this letter is met.
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 RFA. Our reviewer says that the
service is not medically necessary. Our physician reviewer found there is a utilization limit that this request
exceeds, and the use of a chemical ablation is not standard 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 the RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve Chemical Radiofrequency Ablation (RFA) to the lumbar spine (64635 and 64636).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a stay at a SNF on November 20 to
December 12, 2020, and on December 23, 2020, to January 13, 2021.

You asked the Plan to waive the coinsurance for a stay at a SNF. You say that the claims at issue were
submitted incorrectly and that you are being balance billed by the facility. The Plan denied your request. The
Plan says the correct coinsurance was applied.

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 2020 contract with the Plan clearly says that you must pay
10% coinsurance for each stay for Medicare-covered services for each benefit period. Your 2021 contract with
the Plan clearly says that you must pay 20% coinsurance for each day for days 21 to 100 for Medicare-covered
services for each benefit period.

You have been asked to pay $504.25, or 10% of the Medicare-allowed charge of $5,042.51, for a stay at a SNF
on November 20 to November 30, 2020. You have also been asked to pay $550.09, or less than 20% of the
Medicare-allowed charge of $5,500.92, for a stay at a SNF within the same benefit period on January 1 to
January 13, 2021. A stay at a SNF falls within the "Skilled nursing facility (SNF) care" benefit category. This
means that you have been asked to pay less than or equal to the full and 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 a stay at a SNF on November
20 to December 12, 2020, and on December 23, 2020, to January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from February 11, 2021, through February 16, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services 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 $403 copayment per day, for days 1-5 beginning with the day of the admission and a $0 copayment per day, for days 6 and beyond.
You have been asked to pay $2,015 ($403 copayment x 5 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from February 11, 2021, through February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on April 5, 2021.
You asked the Plan to pay for the complete series of x-rays. You say that these x-rays were necessary to evaluate your oral health and you cannot afford this bill. The Plan denied your request. The Plan says this type of x-ray service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on April 5, 2021.