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

We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller with harness, and electronic connection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature is not covered. The rules say that an expandable controller with harness and electronic connection is approved for multiple power options. We looked at the file and Medicare rules. The requested power seat elevation system is not covered by Medicare for any indication. The requested expandable controller with harness and electronic connection are not covered because they are not needed to control the approved power options. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller with harness, and electronic connection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits, injection services, and drugs provided by a chiropractor from January 14, 2021, to February 11, 2021.

You asked the Plan to pay for chiropractic services. You say that you were receiving these services prior to switching to this Plan, were not properly informed, and are on a fixed income. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that they have approved coverage for the manual manipulation services you received.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for office visits, injection services, and drugs provided by a chiropractor from January 14, 2021, to February 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on December 1, 2020, to December 29, 2020.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you are a veteran, and you think that this should be covered fully. The Plan denied your request. The Plan says the correct copayment has been 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 contract with the Plan clearly says that you must pay a $0 copayment per day for days 1-20. There is a $160 copayment per day for days 21-62. There is a $0 copayment for days 63-100 for skilled nursing facility (SNF) care/in-network.
You have been asked to pay a $0 copayment per day for days 1-20. There is a $160 copayment per day for days 21-33 for a skilled nursing stay.
Total Amount Being Asked to Pay: $0 + $2,080 = $2,080
A skilled nursing stay falls within the skilled nursing facility (SNF) care/in-network 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 a skilled nursing stay provided by a participating provider on December 1, 2020, to December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laser iridectomies provided on January 19, 2021, and January 26, 2021.
You asked the Plan to waive the copayments for laser iridectomies. You say that you are still suffering complications due to COVID-19 and cannot work due to it. 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 $150 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.
The record shows that you received a laser iridectomy at an ambulatory surgical center on January 19, 2021. A laser iridectomy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment. The record shows that you received a laser iridectomy at an ambulatory surgical center on January 26, 2021. A laser iridectomy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment. The total amount you owe is: $300. You have been asked to pay the total copayment amount of $300 for laser iridectomies. Laser iridectomies fall within the outpatient surgery and other medical 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 laser iridectomies provided on January 19, 2021, and January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on December 8, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 CPT code 80307 and G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auricular peripheral nerve stimulation (PENS).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that auricular PENS is non-covered. We looked at the file and Medicare rules. The services at issue are auricular PENS. These service are denied by Medicare as non-covered. Therefore, we decided that the Plan does not have to pre-approve auricular peripheral nerve stimulation (PENS).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 20, 2021.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state. Therefore, we are unable to use LCD L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below-knee alignable system.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the current item is not irreparably damaged.
The Plan must follow Medicare rules. Medicare rules say that replacement DME is covered in cases of irreparable damage or when the item as exceeded the reasonable lifetime period of five years.
We looked at the file and Medicare rules. The file shows that the requested alignable system described by code L5910 is included in the enrollee's approved prosthetic socket from November of 2020. The current socket is not irreparably damaged or more than five years old. Therefore, we decided that the Plan does not have to pre-approve a below-knee alignable system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 10, 2020 out of network.
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent 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 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 physician services provided to the enrollee on July 10, 2020 provided out of network.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the SPECT test and the Part B drug provided on March 18, 2021.
You asked the Plan to waive the cost share for the SPECT test and the Part B drug. You say that no one told you that you would have this copayment. You say you would have refused the services if you knew about the cost. 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 $325 copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds and 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. You have been asked to pay a $325 copayment for the SPECT test and $47.50 which is 20% of the allowed amount for the Part B drug. The allowed amount is $237.48. ($237.48 x 20% = $47.50). The SPECT test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B drug falls 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 cost share for the SPECT test and the Part B drug provided on March 18, 2021.
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 this is medically necessary. The Plan denied your request. The Plan says you do not have complex needs.
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 you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond August 4, 2021.
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are 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 approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the SNF after hospitalization for a right pubic and sacral spine fractures. The therapy note on August 2, 2021 states you reached your maximal level of function with walking 20 feet with a walker. You are medically stable with no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression gloves.
You asked the Plan to pre-approve compression gloves. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says compression gloves are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare may cover items that meet the definition of DME, surgical dressings, or braces. In this case, the requested compression gloves do not fall into any of these benefit categories. It is a non-reusable supply which is not being used as a dressing over a qualifying wound and is not rigid or semi-rigid.
Although this item may be appropriate for you, neither Medicare nor your Plan provides coverage for this.
Therefore, we decided that the Plan does not have to pre-approve compression gloves.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam provided on November 6, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the tissue exam. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the tissue exam provided on November 6, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L2-3 and L3-4 levels (CPT 22869 and 22870) is 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular testing provided on January 11, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for molecular testing. You say that you would like this claim reprocessed and paid.
You say that these services were requested by an in-network provider. The Plan denied your request. The Plan
says prior authorization was not obtained by a participating provider. The Plan says that the referring provider
is out-of-network.
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 had network providers
available who could have provided 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 molecular testing provided on January 11, 2021 by
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray services provided on April 27, 2021.
You asked the Plan to pay for the chest x-ray. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Review of the file shows that the chest x-ray was billed with diagnosis code F17.200 (Nicotine dependence, unspecified, uncomplicated). This means that the chest x-ray at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the chest x-ray services provided on April 27, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided from October 1, 2020, through October 30, 2020.

You asked the Plan to waive the copayment for occupational therapy. You say that she has Alzheimer's and cannot comprehend what goes on in occupational therapy. You say that you do not agree with the decision to do occupational therapy and you should not be liable for the charges. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for each Medicare-covered therapy visit from an in-network provider for The enrollee has been asked to pay $560.18, which is less than the standard $40 copayment per visit for occupational therapy. Occupational therapy falls within the "Outpatient rehabilitation services" benefit category. The records show occupational therapy services were provided. 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 occupational therapy provided from October 1, 2020, through October 30, 2020.