Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2025) and lenses (V2100, V2799) provided on March 23, 2021.
You asked the Plan to pay for eyeglasses and lenses. You say that you are receiving two claims with different amounts owed and would like the Plan to reimburse you the difference. The Plan denied your request. The Plan says there is no coverage with an out-of-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when it is provided by an in-network provider. We looked at the file and the Plan's rules. The records show that the service at issue was provided by an out-of-network provider. This service is not covered by the Plan when provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses and lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2025) and lenses (V2100, V2799) provided on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care from August 2, 2021, through August 3, 2021.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care from August 2, 2021, through August 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care from February 9, 2021, through February 12, 2021.

You asked the Plan to pay for inpatient hospital care. You say that you want reimbursement for this claim The Plan denied your request. The Plan says coding and billing guidelines do not support code J12.82 (pneumonia due to coronavirus disease 2019) as the secondary diagnosis; therefore, this code will not be reimbursed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis codes J96.01 defined as acute respiratory failure with hypoxia and J12.82 defined as pneumonia due to coronavirus disease 2019. 

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 inpatient hospital care. Our reviewer says that the medical records did not support the billing of ICD-10-CM diagnosis codes J96.01 (acute respiratory failure with hypoxia) and J12.82 (pneumonia due to coronavirus disease 2019). Our physician reviewer found there was no documentation for the diagnosis of COVID-19 related pneumonia throughout the medical records. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care from February 9, 2021, through February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on March 22, 2021.

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 record indicates the billed code of L1848, this was corrected and updated to an L1833 at the prior level of appeal by the Plan.

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. There was no proof of delivery. 

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 to pay for a knee orthosis (L1833) provided to the enrollee on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplies for a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you are no longer able to prick your finger due to pain and your skin being so thin. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve supplies for a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthetic socket.
You asked the Plan to pre-approve a replacement prosthetic socket. You say that the requested replacement prosthetic socket is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested replacement prosthetic socket.
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 a replacement prosthetic socket.
Our reviewer says that the enrollee does not meet criteria for the requested replacement prosthetic socket. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets criteria for the requested replacement socket. Records do not address the previously supplied socket from 03/31/2021 or why this equipment no longer meets the enrollee's needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement prosthetic socket have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthetic socket.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide provided on February 12, 2021.
You asked the Plan to pay for a stair glide. You say that the chair provides all the medical assistance that you require as prescribed by your physician. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the echocardiography provided on March 18, 2021.

You asked the Plan to waive the coinsurance for the echocardiography. You say that you were unaware you would have a bill. The Plan denied your request. The Plan says you were charged this 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 20% coinsurance for Outpatient Diagnostic Tests. 

You have been asked to pay 20% coinsurance for the echocardiography. The echocardiography falls within the Outpatient Diagnostic Tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the echocardiography provided on March 18, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the Advanced Life Support (ALS) services provided on March 12, 2021.
You asked the Plan to pay for the ALS services. You say that you do not know why the Wayne County showed up as they did not help you. You also say that you should not be held financially liable for the $525 that you are being billed. The Plan denied your request. The Plan says that you did not receive ALS services. The Plan also says that the enrollee did not require ALS evaluation.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the ALS services. Our reviewer says that the ALS services are considered medically reasonable and necessary in this case. Our physician reviewer found that the prudent layperson criteria for emergency care has been met based on your recent medical history. The reviewer found that the documentation supports that another means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) was contraindicated in this case. The documentation supports that you needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The reviewer also found that given your medical history, the documentation supports that ALS services would potentially be needed for manual defibrillation or cardioversion, and/or cardiac pacing. Therefore, the reviewer found that the ALS intercept services were medically reasonable and necessary in this case. 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 ALS services have been met. Specifically, the file shows that your recent medical history supports that ALS services would potentially be needed. Therefore, we decided that the Plan has to pay for the Advanced Life Support (ALS) services provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MI Profile (CPT code 81479) provided to the enrollee on January 3, 2021.

You asked the Plan to pay for the laboratory services. You say that the services were medically necessary and are covered by Medicare. The Plan denied your request. The Plan says the MI Profile is not listed as a test that has been evaluated and has therefore not met Medicare's criteria for medically necessary and reasonable. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The MI Profile has not undergone to process of approval and evaluation through MoIDX. Therefore, we decided that the Plan does not have to pay for the MI Profile (CPT code 81479) provided to the enrollee on January 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Pertuzumab and Trastuzumab provided on February 2, 2021.

You asked the Plan to pay for the provided drugs. The Plan denied your request. The Plan says experimental or investigational services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 provided drugs. Our physician reviewer found that the drug combination is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

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 provided drugs have not been met. Therefore, we decided that the Plan does not have to pay for Pertuzumab and Trastuzumab provided on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus vaccine provided on February 24, 2021.

You asked the Plan to pay for the Coronavirus vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the pharmacy has been contacted and instructed to submit their claim for payment to Original Medicare and to stop billing the enrollee.

The Coronavirus vaccine is to be billed directly to Original Medicare by the rendering pharmacy or physician's office. The Plan follows the same rules. The Plan has contacted the pharmacy and counseled them on retracting this claim and billing it correctly to Original Medicare. Therefore, we decided that the Plan does not have to pay for the Coronavirus vaccine provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 11, 2021.

You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the dental services you received are not covered under the Plan's supplemental 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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on March 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from February 1, 2021, through February 23, 2021.
You asked the Plan to pay for the home health services as billed. You say that a valid HIPPS code was reported on line 1 as 2BFKS. This should be paid. The Plan denied your request. The Plan says the HIPPS code reported is not valid for services rendered beyond December 31, 2019.
The Plan must follow Medicare rules. Medicare rules say that for services provided starting on January 1, 2020, the HH PPS recognizes a new set of 432 HHRGs, represented by a set of HIPPS codes. Review of the HIPPS code master list for services provided from January 1, 2020 does not list HIPPS code 2BFKS as a valid code. Payment cannot be made without a valid HIPPS code. Therefore, we decided that the Plan does not have to pay for the home health services provided from February 1, 2021, through February 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on 
November 16, 2020. 
 
You asked the Plan to pay for these 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 services 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 these services. Therefore, we decided that the 
Plan does not have to pay for outpatient mental health care provided to the enrollee on November 16, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (CPT code L1833), and suspension sleeves (CPT code L2397) provided to the enrollee on November 2, 2020.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.
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 orthoses and sleeves. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient credible objective documentation of joint laxity. 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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (CPT code L1833), and suspension sleeves (CPT code L2397) provided to the enrollee on November 2, 2020.