Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the visit you had with an out-of-network optometrist on April 12, 2021.
You asked the Plan to waive the deductible for the visit with an out-of-network optometrist. You say that this service should be covered 100% since it was coded correctly. You say that the deductible does not apply to diabetic eye exams. The Plan denied your request. The Plan says that you have been charged the full amount because you had not yet met your deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $400 deductible which applies to most medical services. You are correct that according to your contract, the deductible does not apply to diabetic eye exams. However, diabetic eye exams are required to be billed with specific procedure codes that denotes a diabetic eye exam was performed. In this case, your optometrist billed this as a regular office visit with code 99213, which is not a code for a diabetic eye exam. That is why the deductible applied. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible. This cost sharing is a contractual obligation that had not been met at the time the visit with an out-of-network optometrist was received on April 12, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for the visit you had with an out-of-network optometrist on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental consultation (D9310) surgical extraction of
erupted teeth (D7210) provided March 1, 2021 to March 5, 2021.
You asked the Plan to pay for the dental services. You say that from the statement submitted, the Plan paid
$55.00 toward the bill, not 50% of the bill as stated in the Plan. You would like this all reviewed and paid at
50% per the Plan. The Plan denied your request. The Plan says the claim was processed with the correct
coinsurance applied. D9310 is not covered under the Plan benefits.
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 50% coinsurance for extractions and oral surgery procedures.
Services not listed are not covered by the Plan.
You have been asked to pay $391.00 ($55.00 + $177 + $159.00) for the dental services. The health plan
contract states that if you choose to see an out of network dentist, you might be billed for charges above what
the Plan pays, even for services listed as $0 copayment. The services fall within the Dental services 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 pay for the dental consultation (D9310) surgical extraction of erupted
teeth (D7210) provided March 1, 2021 to March 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you had a nasty fall and have problems with your neck and shoulders. You say that you have damage from a previous accident that has been worsened from this accident. You say that your walking is unsteady and that your balance is completely off. You say that you tilt to the right when you walk. You say that you live alone and have to climb several steps to get in your front door. You say that you need physical therapy in an inpatient setting before you can safely return home.
The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The
Plan says that the enrollee's needs can be met in an alternate level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications, had stable vital signs, and was treated for delirium. The enrollee received physical therapy and
occupational therapy in the acute hospital. The enrollee was at a contact guard to minimal assist level with
functional mobility including gait to 100 feet. The enrollee required varying assist with activities of daily
living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service
needs, however they are not required on a daily basis. The enrollee does not meet the severity of illness or
intensity of service criteria for an inpatient basis in a SNF setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308), muscle or fascia debridement (11043), and subcutaneous tissue debridement (11042) provided on March 30, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care services. You say that the services were provided at the request of the enrollee's primary care physician. You also say that the services were medically necessary. The Plan denied your request. The Plan says authorization was not obtained prior to the services being rendered to the enrollee. The Plan also says that there are contracted providers available.
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 the subsequent nursing facility care (99308), muscle or fascia debridement (11043), and subcutaneous tissue debridement (11042) provided on March 30, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81413, 81238, 81406, 81407, 81408, 81161,81414, 81411, 81405, 81406 and 81408) provided to the enrollee on January 20, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Medicare denies coverage for all cardiovascular risk assessment testing / panels for suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81413, 81238, 81406, 81407, 81408, 81161,81414, 81411, 81405, 81406 and 81408) provided to the enrollee on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulator.

You asked the Plan to pre-approve the stimulator. You say that this is medically necessary to help raise the left foot and walk easier. The Plan denied your request. The Plan says very little clinical information was received about the illness.

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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is not clear that the foot drop is exclusively due to the stroke. Per a 5/8/21 physical therapy note, you had a stroke in 2013, with left-sided weakness. However, you also began to have left knee, ankle, and bilateral calf pain that started two years ago. You report numbness and tingling from your diabetes in both feet. Furthermore, the documentation indicates that you have low back and right hip pain.

The documentation does not support that the etiology of your foot drop is purely from her stroke. The foot drop may also be caused by lumbar radiculopathy, peripheral neuropathy from conditions such as her diabetes mellitus or Vitamin B12 deficiency or an additional etiology. There is no evidence of an electrodiagnostic study, imaging studies, or a very detailed physician generalized neuromuscular examination supporting a need for this device. Without a clear evaluation of the cause of your pain, this device is not indicated. 

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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress (CPT code E0295), bed side rails (CPT code E0305) and mattress, innerspring (CPT code E0271), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee requires a hospital bed/lift to assist with sustaining health, rehabilitation and care-taking goals. 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 DME. Our physician reviewer found based on the medical records provided there is no documentation that meets all of the requirements listed in the Local Coverage Determination (LCD): Hospital Beds and Accessories (L33820) for Medicare coverage of the requested semi-electric hospital bed. The provided records do not document that the enrollee has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed, that the enrollee requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain or requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease or problems with aspiration or requires traction equipment, which can only be attached to a hospital bed. Records do not document the enrollee requires frequent changes in body position and/or has an immediate need for a change in body position. 
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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress (CPT code E0295), bed side rails (CPT code E0305) and mattress, innerspring (CPT code E0271), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from January 29, 2020 to March 5, 2020.
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 claim was not filed timely per Medicare guidelines.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the dental services was not filed until June 8, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the dental services provided from January 29, 2020 to March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented, calibrated gradient pneumatic compression device (PCD) (E0652) with appliance.

You asked the Plan to pre-approve gradient PCD. You say that the enrollee has failed conservative therapy and a 4-week trial with a basic pump. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee only has swelling in the legs which does not extend into the trunk or abdomen.

The Plan follows Medicare rules. Medicare rules state that a segmented, calibrated gradient pneumatic compression device coded as E0652 is only covered for lymphedema extending into the chest, trunk, and/or abdomen. 

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 gradient PCD. Our reviewer says that the enrollee does not meet the Medicare criteria for an E0652 pneumatic compression device. Our physician reviewer found the records provided show that the enrollee has swelling only in the legs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gradient PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented, calibrated gradient pneumatic compression device (PCD) (E0652) with appliance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the special PWC with two (2) or more power seat options (power tilt, power recline and power seat lift) (CPT code(s): K0861, E2363, E1007, E2620, E0955, E1028, E1012, K0040, E2377, E2313, E2311, E2607, E2300, E1028), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the enrollee does not have a medical need for multiple power options included with group 3 power wheelchair (K0861). The Plan states electronic connection (E2311), expandable Controller (E2377) and expandable controller harness (E2313) cannot be covered as it is not medically necessary to control the three requested power options through the joystick (drive interface). The Plan states the seat elevator (E2300) does not serve a primary medical purpose and are statutorily non-covered.
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. 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 DME. Our physician reviewer found the documentation indicates the enrollee has a mobility deficit that impairs mobility-related activities of daily living (MRADLs) in the home and is not ameliorated by a walker, cane, manual wheelchair due to shoulder pain and weakness. While the enrollee may be able to safely operate a power mobility device (PMD) the requested K0861 with multiple power options exceeds the enrollee's medical need. The documentation does not reveal that the enrollee needs is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). The enrollee's strength should be sufficient to control any power options through their own switches. The documentation does not reveal that tilt and recline are medically necessary therefore the request for Group 3 power wheelchair with multiple power options is not medically necessary per LCD: Wheelchair Options/Accessories (L33792) and Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the special PWC with two (2) or more power seat options (power tilt, power recline and power seat lift) (CPT code(s): K0861, E2363, E1007, E2620, E0955, E1028, E1012, K0040, E2377, E2313, E2311, E2607, E2300, E1028), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on March 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 75710 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 75710 (angiography of extremities) and 37226 (endovascular revascularization). Code 75710 is a column II code with a modifier indicator of 1 when billed with column I code 37226. Code 75710 is not supported for separate payment by the submitted documentation. Therefore, we decided that the Plan does not have to pay for the imaging services rendered on March 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography, thorax,
diagnostic; without contrast material (71250) provided on April 12, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that you must pay a $150 copayment per visit for all other outpatient
diagnostic and therapeutic services and supplies, such as magnetic resonance angiography (MRAs), magnetic
resonance imaging (MRIs), computed tomography (CT) scans, positron emission tomography (PET) scans, and
hyperbaric oxygen therapy.
You have been asked to pay a $135.31 copayment for the computed tomography scan provided. This is the
Plan's allowed amount for this service, which is less than the applicable copayment. 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 computed tomography, thorax, diagnostic; without contrast material (71250)
provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would consideration on helping this unfortunate man. The Plan denied your request. The Plan says there are in-network providers available 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 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 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-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the transthoracic echocardiography (93306) provided on February 5, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.

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 20% coinsurance for outpatient diagnostic procedures/tests (Electrocardiogram (EKG), electroencephalogram (EEG), sleep studies).

You have been asked to pay $92.88 (Plan allowed amount of $464.40 x 20% coinsurance) for the outpatient diagnostic test provided. 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 transthoracic echocardiography (93306) provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Remicade infusion you received on
February 11, 2020.
You asked the Plan to waive the coinsurance for the Remicade infusion. You say that you do not believe you
owe this coinsurance because you never received a bill from your doctor. 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 Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Remicade infusion. The Remicade infusion falls within
the Medicare Part B drugs benefit category. This cost sharing applies regardless of when you are billed.
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 Remicade infusion you received on February 11, 2020.