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

We decided that the Plan does not have to pay foran ankle-foot orthosis (L1932, L2820)You asked the Plan to pay forthe orthoses. You say that the medical records reflect coverage criteria.The Plan denied your request. The Plan saysthe physician order was invalid.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. The submitted order indicates an ankle foot orthosis (AFO) was ordered. However, there are multiple HCPCS codes for various AFO braces, the physician order does not reflect specificity in regards to L1932 versus any other billed AFO code.Therefore, we decided that the Plan does not have to pay foran ankle-foot orthosis (L1932, L2820)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MTHFR genetic testing.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says MTHFR testing is not covered.The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is denied as not medically necessary.The testing at issue is MTHFR genetic testing. This testing is denied by Medicare as not medically necessary.Therefore, we decided that the Plan does not have to pre-approveMTHFR genetic testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe denosumab injection provided on September 11, 2019.You asked the Plan to waive the coinsuranceforthe denosumab injection. You say that you bought this through the pharmacy before the appointment. You say that you should not have to pay.The Plan denied your request. The Plan says the coinsurance 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 20% of the total cost for other Medicare-covered Part B prescription drugs.You have been asked to pay $241.98, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,209.91 (20% x $1,209.91 = $241.98). The denosumab injection 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 nothave to waive the coinsurance forthe denosumab injection provided on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 27, 2018.You asked the Plan to pay for the laboratory services. You say that this was medically necessary testing.The Plan denied your request. The Plan says a site investigation was completed and it was found that the address listed on these claims does not house a laboratory owned by the billing company, nor has there ever been a laboratory there. As such, this claim is not payable due to the fraudulent address reported.The Plan must follow Medicare rules. Medicarerules say that all information must corroborate the documentation in the record and support that coverage criteria are met. In this case, the Plan attests that the address listed on this claim is not valid as there is no laboratory operating at that address. As such, we find that this claim does not corroborate other information in the record and is correctly denied.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on December 27, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the records provided support the need for LTACH care.The Plan denied your request. The Plan says the records received do not indicate that the enrollee meets the criteria for coverage of LTACH care. The Plan says that LTACH care is not medically necessary because the enrollee does not have complex illness requiring her to see a doctor every day.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for multifactorial shortnessof breath. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services provided on October 21, 2019 through October 22, 2019.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the correct format for portions of this claim should have been billed on a CMS-1500 form.
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 looked at your request, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Specifically, CPT code J7613 has a payment status indicator of M. This means that CPT code J7613 is not billable to the MAC. Therefore, we decided that the Plan does not have to pay for emergency department services provided on October 21, 2019 through October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided on July 18, 2019, September 19, 2019 and October 24, 2019.
You asked the Plan to waive the copayment for the office visits. You say that you were not informed the provider is a specialist. You say that you should be charged for a primary care physician. 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 $50 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $50 copayment for each office visit. The total amount you owe is $150 ($50/visit x 3 visits = $150). The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a geriatric specialist. 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 office visits provided on July 18, 2019, September 19, 2019 and October 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy provided on August 29, 2019.You asked the Plan to waive the copayment forthe endoscopy. You say that no one told you the copayment would be so high for the colonoscopy. You say you disagree with the member liability and you do not feel like you should pay the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient hospital facility. You have been asked to pay a $400 copayment for the endoscopy. The endoscopy falls within the "Outpatient hospital services" benefit category. The recordshows you were charged for the endoscopy and not for the colonoscopy.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 inthe Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe endoscopy provided on August 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device.
You asked the Plan to pre-approve the CardioMEMs device. You say that the CardioMEMs device is medically necessary. The Plan denied your request. The Plan says the current evidence is insufficient to support the use of ambulatory cardiac hemodynamic monitoring using an implantable pulmonary artery pressure measurement device in individuals with heart failure in an outpatient setting.
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 CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time and not recommended in current guidelines for the treatment of heart failure. The device should still be considered experimental or investigational. 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 CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on October 8, 2019.You asked the Plan to waive the copayment forthe eye exam. You say that you were told your benefits would only pay for a medical eye exam. You say that you thought this was a routine eye exam.The Plan denied your request. The Plan says the copayment 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 $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that this was a medical eye exam. This means that youhave 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 forthe eye exam provided on October 8, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based filling (D2393) provided on November 13, 2019.You asked the Plan to pay for the resin-based fillings (D2393). You say that this service should be covered because you have dental insurance. The Plan denied your request. The Plan says the service is not a covered benefitMedicare 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 resin-based fillings (D2393) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe resin-based filling (D2393) provided on November 13, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Flexitouch pneumatic compression device from an out-of-network provider.You asked the Plan to pre-approvethe Flexitouch pneumatic compression device. You say that Tactile Medical is the manufacturer and only supplier of the Fleixitouch device. You say that this device cannot be obtained through an in-network provider.The Plan denied your request. The Plan says there are contracted providers who can supply a pneumatic compression device.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contractproviders for care. 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 Flexitouch pneumatic compression device. Our reviewer says that the criteria for out-of-network care have not been met. Our physician reviewer found the health plan is offering adequate care to meet the enrollee's medical needs through referral to a non-Flexitouch device. There is nothing unique about the enrollee's condition that that would make it medically necessary for her to see the requested out-of-network provider. There is insufficient evidence that the Flexitouch is superior in treating the enrollee's lymphedema over the in network approved E0652 device. The plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the patient's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the Flexitouch pneumatic compression device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Flexitouch pneumatic compression device from an out-of-network provider.
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 enrollee needs supervision due to bladder and blood stream infection. You say that the enrollee has mobility issues, special needs, and is intellectually disabled. You say that a skilled nursing facility (SNF) is unable to handle the enrollee's needs. The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says that the enrollee does not have complex medical needs that require physician visits three times a week and does not require an intensive multi-team approach to rehab. The Plan says that the enrollee does not require specialized staff or equipment of an IRF. The Plan says that the enrollee's needs can safely be met at a lower level of care, such as a SNF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week. There is no evidence of complex medical issues that require acute rehab nursing care. While the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of a need for an intensive therapy program with therapy for 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1851,L2397) provided to the enrollee on August 12, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe mammogram provided on October 15, 2019.You asked the Plan to waive the copayment forthe mammogram. You say that you have had a mammogram for 6 years and never been charged. You say that the Plan should take care of the bill.The Plan denied your request. The Plan says the claim was reprocessed to only apply the copayment.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for diagnostic lab services and diagnostic procedures and tests. You have been asked to pay a $10 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that a diagnostic mammogram was ordered and performed. 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 forthe mammogram provided on October 15,2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies and sterile gloves.You asked the Plan to pre-approve incontinence supplies and sterile gloves. You say that the enrollee needs these supplies.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 incontinence supplies and sterile gloves are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neitherthe Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies and sterile gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair power seat elevation system from Numotion.You asked the Plan to pre-approvea power seat elevation system (2300). You say that the power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says power seat elevation systems are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair power seat elevation system.