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

We decided that the Plan does not have to waive the copayment for the biopsy on July 13, 2020. You asked the Plan to waive the copayment for the biopsy. You say that the letter did not state that a copayment would still apply to a procedure. You say you should not have to pay the copayment. 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 $200 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $200 copayment for the biopsy. The biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the biopsy provided on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313) with electronic connection (E2311) for a Group 3 power wheelchair.
You asked the Plan to pre-approve an expandable controller and harness with electronic connection. You say that the requested power options for a Group 3 power wheelchair are medically necessary for the enrollee. The
Plan denied your request. The Plan says rules for pre-approval have not been met because there is not a medical need to control the requested power options through the joystick.
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 an expandable controller and harness with electronic connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the right upper extremity with the ability to lift a gallon of milk, feeding and perform independent hygiene indicates that the enrollee should be able to control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller and harness with electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313) with electronic connection (E2311) for a Group 3 power wheelchair.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis, cellulitis and right foot osteomyelitis. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on November 5, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you were not informed of a copayment before the MRI was performed. You say that you should not be asked to pay. 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 $225 copayment for each Medicare-covered advanced imaging service from an in-network provider. You have been asked to pay $209.90, which is less than the standard $225 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the MRI provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 24, 2020.
You asked the Plan to pay for a limited oral evaluation. You say that you do not understand why the Plan is denying payment for this service. The Plan denied your request. The Plan says there is no coverage for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this is for safety reasons. The Plan denied your
request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. 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. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 19, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was an annual wellness visit. 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 $10 copayment for a primary care provider visit. The medical records show that you received services beyond an annual wellness exam on October 19, 2020. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for 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 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 lab work provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services provided on July 3, 2020. You asked the Plan to pay for the paramedic intercept services. You say that you thought you were having a heart attack when you called for an ambulance. You say that the fire company which arrived did not have a paramedic or volunteer ambulance company and had to meet the paramedic intercept at the county line. You say that the paramedic got into the ambulance and determined you were having a heart attack, so they took you to the hospital. The Plan denied your request. The Plan says the requirements for coverage of paramedic intercept services have not been met. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on July 3, 2020.
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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) with suspension sleeve (L2397) provided on September 12, 2020.
You asked the Plan to pay for a knee orthosis with suspension sleeve. You say that the requested items were legally and accurately prescribed by the physician. The Plan denied your request. The Plan says rules for payment are not met because no medical records were provided showing that the prescribing physician ever saw the enrollee.
The Plan follows 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 pay for a knee orthosis with suspension sleeve. Our reviewer says that the requested items are not medically necessary and reasonable. Our physician reviewer found that 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 Medicare. There is insufficient documentation of an appropriate evaluation of the enrollee, and 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 a knee orthosis have not been met. Furthermore, the requested suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) with suspension sleeve (L2397) provided on September 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the consultation (D9310).

You asked the Plan to pay for the dental services. You say that you were advised prior to the appointment that this provider was in network. You say that you told the provider that you only wanted to have services that would be covered by your insurance. You also say that you disagree with the denial as you did not receive coverage for "evaluation and consultation." The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that consultation is not listed as a covered service.

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 and comprehensive oral evaluation is listed as a covered service, the frequency limit of 1 every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation. Additionally, consultation is not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the consultation (D9310).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cooled RFA (CPT code(s) 64635 x2 and 64636 x2).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found Cooled RFA does not meet the criteria of Medicare. RFA of the Sacroiliac (SI) joints is considered experimental/ investigational because of the wide variation of efficacy in the peer reviewed literature. You have an extruded disc displacing the L3 nerve root which is another probable pain generator. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Cooled RFA (CPT code(s) 64635 x2 and 64636 x2).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the alginate gel and foam wound dressings provided on November 3, 2020.
You asked the Plan to pay for the surgical dressing provided. You say that the dressings being billed are not the dressings used on the date of the debridement but rather represent dressings that were provided to the patient for use after the professional services. This is covered by Medicare. The Plan denied your request. The Plan says that the two codes at issue have a status indicator of "P" on the Physician Fee Schedule which means "No separate payment should be made for them under the fee schedule; If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident".
The Plan must follow Medicare rules. Medicare rules say that while no separate payment is made for dressings that are provided during a physician's service, payment can be made for dressings that are sent home with the patient when the POS code corresponding to their residence is reported. In this case, the enrollee resides in a nursing facility. There is documentation showing that these dressings were ordered and delivered to the enrollee at their residence in amounts that would only be used in the times beyond the discrete physician visit during which some dressings were applied. While payment is not made for these on the Physician Fee Schedule, payment can be made on the Durable Medical Equipment (DME) fee schedule for dressing provided in this situation. Therefore, we decided that the Plan has to pay for the alginate gel and foam wound dressings provided on November 3, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on October 13, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the ordering physician is treating the beneficiary. Of note, the member and laboratory are located in Texas and the ordering physician is located in Illinois. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for knee arthroscopy (29874) provided on October 6, 2020.
You asked the Plan to pay for the knee arthroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says billed procedure code 29879 supports one unit for the date of service but the provider billed two units.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 29874 is one. You billed two units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for knee arthroscopy (29874) provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a Continuous Positive Air Pressure (CPAP) machine (E0601).
You asked the Plan to pre-approve continued coverage for the CPAP machine. You say that continued coverage is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that for continued coverage, the enrollee must use the CPAP machine for 4 or more hours a day on 70% of days. We looked at the file and Medicare rules. The record clearly shows the enrollee only used the CPAP machine on 10% of days. The documentation shows the enrollee only used the CPAP for more than 4 hours on a single night. Based on this information, we decided that Medicare rules for coverage of continued coverage for the CPAP machine have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of a Continuous Positive Air Pressure (CPAP) machine (E0601).