Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan hasto pay for a shoulder arthroscopy (29827).You asked the Plan to pay for the shoulder arthroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that The medical records did not include documentation of a surgical shoulder arthroscopy, with rotator cuff repair; therefore this code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report serviceswith the appropriate CPT code. In this case, the CPT Code Manual definition of code 29827-22-RT is arthroscopy, shoulder, surgical; with rotator cuff repair.We asked our coder 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 shoulder arthroscopy. Our reviewer says that modifier 22 is appended to the basic CPT procedure code when the services provided are greater than usually required for the listed procedure. Use of modifier 22 allows such a claim to be considered individually. Our reviewer found the case file contains documentation in the operative report, and a cover letter explaining the unusual circumstances in this shoulder arthroscopy. The documentation included descriptive statements identifying the difficult unusual circumstances in the operative report.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder arthroscopy have been met. Therefore, we decided that the Plan has to pay for a shoulder arthroscopy (29827). If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary. Our physician reviewer found that Euflexxa is being requested for the treatment of osteoarthritis in the right knee. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. Without the support of the documentation, Euflexxa is not medically necessary, as step criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services received on September 10, 2017.
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 claim was paid correctly.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The plan has paid for your primary deductible, but is not responsible for the coinsurance, as they needs to be paid by your primary insurance. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for hospital services received on September 10, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the folding wheeled walker provided on May 31, 2019 by OON provider. You asked the Plan to pay for the folding wheeled walker (E0143). You say that the walker was medically necessary so the Plan should pay this claim. The Plan denied your request. The Plan says you did not requestprior 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the folding wheeled walker provided on May 31, 2019 by OON provider..
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the compression pump is necessary.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. Atleast four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing care (99308) provided on April 10, 2019.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the care was not emergent or preauthorized. There are in-network providers who could have provided these services.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 inthis case is not a network provider with the Plan. The Plan has network providers available who can provide 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 forsubsequent nursing care (99308) provided on April 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit and electrocardiogram (93306, 99215, 93000, 86141) provided on October 17, 2019.You asked the Plan to pay forthe office visit and electrocardiogram. You say that the services should be covered because you have out-of-network benefits.The Plan denied your request. The Plan says the physician has opted out of the Medicare program and the enrollee signed an agreement that states as such.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that has optedout of Medicare. The enrollee signed a private contract with the provider. Based on this information, we decided that Medicare rules for coverage of the office visit and electrocardiogram have not been met.Therefore, we decided that the Plan does not have to pay foran office visit and electrocardiogram (93306, 99215, 93000, 86141) provided on October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmology services (92012) provided on May 10, 2019.You asked the Plan to waive the copayment forthe ophthalmology services. You say that your doctor did the same things to your eyes that he did two years ago and it did not cost you a thing. You are entitled to a free yearly eye exam and want to know why you're being charged.The Plan denied your request. The Plan says the copayment has been applied correctly.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay $35 copayment for Medicare covered vision services with a specialist's office. for Vision care.You have been asked to pay $35 copayment for Medicare covered vision services with a specialist's office. for the ophthalmology services. The ophthalmology services fall within the Vision care benefit category. This means that you have been askedto 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 forophthalmology services (92012) provided on May 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwound care supplies provided on September 17, 2019.You asked the Plan to pay foralginate or other fiber gelling dressing (A6916) and gauze dressing (A6219). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the supplies are included in the skilled nursing facility payment.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that alginate or other fiber gelling dressing (A6916) and gauze dressing (A6219) were used in a SNF or hospital.Theses supplies would have been included in the global paymentsubmitted to the plan by the facility.Therefore, we decided that the Plan does not have to pay forwound care supplies provided on September 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean outpatient surgery to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean outpatient surgery. The Plan denied your request. The Plan says there are in-network available for the service in question.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 Planhas network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvean outpatient surgery to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer bench with a commode and a superslide transfer bench.
You asked the Plan to pre-approve the transfer bench with a commode and a superslide transfer bench. You say that you absolutely need a shower chair commode because you are a double amputee and you need this on a daily basis to take a shower and also use the restroom. The Plan denied your request. The Plan says the requested equipment is viewed as not primarily medical in nature and are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a transfer bench with a commode and a superslide transfer bench
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil.
You asked the Plan to pre-approve the Tadalafil. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a burr hole procedure (61210) provided on April 27, 2019.
You asked the Plan to pay for surgical assistant services on a burr hole procedure. You say that these services should be paid. The Plan denied your request. The Plan says an assistant surgeon is not necessary for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 61210. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services on a burr hole procedure have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a burr hole procedure (61210) provided on April 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT).
You asked the Plan to pre-approve the HBOT treatments. You say that the enrollee has idiopathic sudden sensorineural hearing loss and there is evidence that HBOT can be helpful in this situation. The Plan denied your request. The Plan says Medicare does not cover HBOT for this condition.
The Plan must follow Medicare rules. Medicare rules say that HBOT is only covered for a specific set of conditions. The enrollee does not have one of the conditions for which Medicare allows coverage. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800).
You asked the Plan to pre-approve the power scooter. You say that the power scooter would assist you in the
home just to perform daily activities. The Plan denied your request. The Plan says there is no clinical
documentation that shows the use of a cane or walker will not resolve your mobility limitation, or that you need
the power scooted inside the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The
rules also say that Medicare will pay for durable medical equipment that is needed for use in the home.
The file shows that the documentation does not support that you have a mobility deficit that impairs your
participation in MRADLs, or that your condition would not be improved by a walker, cane or manual
wheelchair. You are able to ambulate around your house without difficulty, and would require the travel
scooter for when you are out of the house. This means that Medicare rules for coverage of a PMD have not
been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
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 October 9, 2019.You asked the Plan to pay for the 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 October 9, 2019
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to apply the in-network rate for the radiation treatments provided from July 5, 2019 to July 30, 2019.
You asked the Plan to apply the in-network rate for the radiation treatments. You say that you received the services through an in-network provider. You say you would like the claims to be reduced to the in-network amount. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The record shows the hospital the radiation treatments were provided at is a contract provider. The file does not show that the Plan provided notice that the radiation treatments provided by the physicians would not be covered as an in-network services. Under Medicare rules, this means the radiation treatments are considered approved by the Plan. Therefore, we decided that the Plan has to apply the in-network rate for the radiation treatments provided from July 5, 2019 to July 30, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
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 services are necessary.The Plandenied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as describedabove.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 was medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee will benefit from further physical therapy (PT) and Speech but does not require an intensive therapy program. IRF admission is not medically necessary based on the current functional status and medical stability.We looked at thisphysician'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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fortheeyeglasses providedon April 26, 2019.You asked the Plan to pay for the eyeglasses. You say that every time you received services from this provider, the Plan paid for the services. The Plan denied your request. The Plan says routine eyewear is covered when provided, generally does not cover routinevision 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 provided..We looked at thefile and the Plan's rules. The provider at issue in this case is not a network vision provider with the Plan's vendor. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on April 26, 2019.