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

We decided that the Plan has to pre-approve a group 2 standard power wheelchair.
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that the item is necessary.
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has
not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility
deficit that impairs their participation in MRADLs, the patient's condition cannot be ameliorated by a walker,
cane or manual wheelchair, and the patient is 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 a group 2 standard power wheelchair.
Our reviewer says that the item is medically necessary. Our physician reviewer found based on the medical
records provided (including a visit note of January 21, 2021) there is documentation that this enrollee has a
personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting,
feeding, grooming and bathing in customary locations within the home. There is documentation that the
enrollee's mobility deficit cannot be adequately helped by the use of a walker, cane or manual wheelchair due
to his level of weakness, instability and shortness of breath. The enrollee can safely operate a power mobility
device.
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 group 2 standard power wheelchair have been met. Therefore, we decided that
the Plan has to pre-approve a group 2 standard power wheelchair.
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 waive the copayment for the blood collection procedure from an
implanted venous access device you received at an outpatient hospital facility on April 24, 2020.
You asked the Plan to waive the copayment for the blood collection procedure. You say that you do not believe
you owe any copayments with this insurance. The Plan denied your request. The Plan says you were charged
this copayment correctly. The Plan says that because the allowed amount for this procedure ($110.73) is less
than your copayment obligation, you are responsible for the full allowed 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 $225
copayment for outpatient hospital procedures.
You have been asked to pay a $225 copayment for the blood collection procedure. The blood collection
procedure falls within the outpatient hospital procedures 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 blood collection procedure from an implanted venous access device you received at an
outpatient hospital facility on April 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 12, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on May 29, 2020, billed with codes
87496, 87498, 87798, 87486, 87541, 87581 and 87640.
You asked the Plan to pay for the lab testing. You say that this was billed correctly for medical necessary
services. The Plan denied your request. The Plan says the incorrect POS code was reported.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. There is not sufficient evidence to support that the sample was taken directly by the lab. As such, POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on May 29, 2020, billed with codes 87496, 87498, 87798, 87486, 87541, 87581 and 87640
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lenses (V2784) provided on April 28, 2021.
You asked the Plan to pay for polycarbonate lenses. You say that you would like the vision services paid. You also say that the provider who performed the services was out-of-network. The Plan denied your request. The Plan says there is no listed benefit for polycarbonate lenses.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that for premium frames, progressive lenses, and additional lens treatment upgrades, the member receives a vision vendor's discounted rate. These are VAIS and are not plan benefits and are not part of the plan's benefit package. We looked at the file and the Plan's rules. The service at issue is not a covered benefit of Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lenses (V2784) provided on April 28, 2021.
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 IRF services are medically necessary. The Plan denied your request. The Plan says 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 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 records show that the enrollee's care needs, as a practical matter, can be provided 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided May 20, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you would like to be reimbursed for these drugs you received. The Plan denied your request. The Plan says the claim has processed correctly.
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 pay for the self-administered drugs provided May 20, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services, deluxe frames (V2020) and lenses, spherocylinder, trifocal (V2303) purchased April 9, 2021.
You asked the Plan to pay for the vision services. You say that you have received cataract surgery and have included your paperwork. It was your understanding that having had cataract surgery Medicare did cover the exam and eyeglasses which you received. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of eyeglasses or contact lenses after each cataract surgery. The record show that you have not recently had cataract surgery. The records show you had cataract surgery in 2004. Therefore, you do not meet the criteria for the vision benefits. We looked at the file and the Plan's rules. The plan covers one pair of eyeglasses or contact lenses after each cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services, deluxe frames (V2020) and lenses, spherocylinder, trifocal (V2303) purchased April 9, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided on January 14, 2021 by a non-participating provider.
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 the services were rendered by a non-participating provider without prior 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 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 telehealth services provided on January 14, 2021 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a podiatrist (99213), debridement of nails (11721), removal of skin growth (11056) and an x-ray of the foot (73620) provided on January 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for podiatry services. You say that had you known the provider was not in-network, you would not have gone to the appointment. 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit with a podiatrist (99213), debridement of nails (11721), removal of skin growth (11056) and an x-ray of the foot (73620) provided on January 12, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a miscellaneous vision service (V2799) provided on March
27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a miscellaneous vision service. You say that you were told that you could go to
an out-of-network provider of choice and then submit a claim. The Plan denied your request. The Plan says
services should be received from network providers who are listed in the provider directory.
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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 a miscellaneous vision service (V2799) provided on March 27,
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for Octogam infusions you received at an outpatient hospital facility from January 25, 2021, to February 24, 2021.

You asked the Plan to waive the cost sharing for the Octogam infusions. You say that you cannot afford these copayments. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the outpatient hospital fees, the allowed amounts for these services is less than your copayment obligation, so you are only responsible for the allowed amounts for the outpatient hospital fees. You are still responsible for the coinsurance for the drug itself.

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 and a $250 copayment for services at an outpatient hospital facility.

You have been asked to pay 20% coinsurance for the Octogam infusions. The Octogam infusion falls within the Medicare Part B drugs benefit category. In addition, you have been asked to pay up to a $250 copayment each time you received services at the outpatient hospital facility. This means that you have been asked to pay the correct amounts 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 cost sharing for Octogam infusions you received at an outpatient hospital facility from January 25, 2021, to February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring represented by code 95941 provided on April 7, 2020.

You asked the Plan to pay for code 95941. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 the file and Medicare rules. In this case, CPT code 95941 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring represented by code 95941 provided on April 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging,
tomographic (SPECT) and the transthoracic echocardiography (TTE), provided on April 6, 2021.

You asked the Plan to waive the copayment for the myocardial perfusion imaging, tomographic (SPECT) and
the transthoracic echocardiography (TTE). You say that the hospital informed you that the copayment would be
$30 or $60. The Plan denied your request. The Plan says your cost-share is correct per your Plan benefits.

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 $125
copayment for other outpatient diagnostic tests - radiological diagnostic services, not including x-rays.

You have been asked to pay a $125 copayment for the myocardial perfusion imaging, tomographic (SPECT)
and the transthoracic echocardiography (TTE). The myocardial perfusion imaging, tomographic (SPECT) and
the transthoracic echocardiography (TTE) falls within the other outpatient diagnostic tests - radiological
diagnostic services, not including x-rays 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 myocardial perfusion imaging, tomographic (SPECT) and the transthoracic echocardiography (TTE),
provided on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on January 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because these services were authorized for an office setting. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.
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 outpatient services provided on January 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a cardiologist (99214) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you have been seeing this provider, who is more knowledgeable with your health and you would like to continue. The Plan denied your request. The Plan says you must receive your care from a network provider.
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 provider at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that there is no specific clinical rationale for continued OON cardiology services. Your condition can be adequately cared for by an in-Plan cardiologist. The review has determined that continued care with the OON cardiologist is not medically necessary at this time. Your care can be safely transitioned to an in-network provider.
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 office visit have not been met. 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 an office visit. Therefore, we decided that the Plan does not have to pre-approve an office visit with a cardiologist (99214) to be provided by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF services provided from

October 21, 2020, through October 25, 2020. (Additional charges were reviewed in a separate appeal)
You asked the Plan to waive the copayment for the SNF services. The Plan denied your request. The Plan says the correct cost share has been applied to the claim.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 0 copayment per day for days 1-20 and a $50 copayment per day for days 21-100. for Skilled Nursing Facility (SNF) Care. 

The enrollee has been asked to pay 0 copayment per day for days 1-20 and a $50 copayment per day for days 21-100. for the SNF services. The SNF services falls within the Skilled Nursing Facility (SNF) Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from October 21, 2020, through October 25, 2020.