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

We decided that the Plan does not have to pay for the CPAP supplies coded as A7028, A7034, A7035, A7037, A7038, A7039, A7044 and A7045 provided November 6, 2019. You asked the Plan to pay for the CPAP supplies. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not support the service billed. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the documentation of itemized shipping/billing invoice to indicate the specific supplies. The record does not contain a valid documentation of itemized shipping/billing invoice to indicate the specific supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the CPAP supplies coded as A7028, A7034, A7035, A7037, A7038, A7039, A7044 and A7045 provided November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system (E2300). You asked the Plan to pre-approve the power seat elevation system. You say that you need the additional add on's for the power wheelchair due to your diagnosis of ALS.The Plan denied your request. The Plan says seat elevator does not serve a primary medical purpose and is statutorily non-covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99233 provided on January 24, 2020.
You asked the Plan to pay for CPT code 99233. You say that the medical records support the billing of CPT code 99233. The Plan denied your request. The Plan says CPT code 99233 was denied because it was reported with a critical care evaluation and management service, 99291.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 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 CPT code 99233. Our reviewer says that the services were not billed appropriately per Medicare guidelines. Our physician reviewer found the documentation submitted was reviewed. No documentation has been submitted to support that codes 99233 and 99291 are significant, separately identifiable E/M services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99233 provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT).You asked the Plan to pre-approve IMRT. You say that this IMRT is medically indicated and would be more sufficient for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this IMRT is correct, because the enrollee does not need IMRT and needs 3-dimensional conformal radiation instead. The Plan follows Medicare rules. Medicare rules say that IMRT is only covered for certain conditions when it is considered medically necessary. 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 IMRT. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested IMRT. Our physician reviewer found the enrollee is being offered palliative radiotherapy for which IMRT is not an accepted standard. The dose being offered is higher than what is typically offered for palliation though the need for this type of dose is not justified in the case records. Guidelines state that IMRT should only be used in the setting of clinical trial or unique situations such as re-irradiation or unique anatomical situations. These criteria do not apply to this case. There is no written rationale as to why IMRT would provide a clinically meaningful benefit or why such a high dose is being used for palliation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.You asked the Plan to pre-approve the SNF services. You say that transfer from acute IP to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy (PT0 in the acute hospital. The enrollee was at an independent to supervision level with functional mobility. She had a right foot drop.Our physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) is not medically necessary on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis in a skilled nursing facility setting. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor V genetic testing.You asked the Plan to pre-approve Factor V genetic testing. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare says testing of variants to the F5 and F2 genes are not covered except for pregnant patients. The file shows that you are not pregnant. Based on this information, we decided that Medicare rules for coverage of Factor V genetic testing have not been met.Therefore, we decided that the Plan does not have to pre-approve FactorV genetic testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient medical services provided on November 22, 2019. 
 
You asked the Plan to waive the cost share for the services provided. You say that you are limited by your income. The Plan denied your request. The Plan says the copay was applied correctly, and the provided drugs are not covered by your medical plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The file shows that Oxycodone was provided. The provided drugs that are usually selfadministered drugs are not among the types which are covered by Medicare Part B. Benefits for the services provided may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights. 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 $325 copay for surgical services in an outpatient hospital facility.  
 
You have been asked to pay a $325 copay for the surgery services you received. The services fall within the outpatient surgery 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 cost share for the outpatient medical services provided on November 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 13, 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. The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP cleaner and sanitizing machine. You asked the Plan to pre-approve the machine. You say that you would like reconsideration because the cleaning equipment is necessary and ineffective cleaning could lead to other issues. The Plan denied your request. The Plan says this is not a Medicare covered benefit and the provider is out-of-network. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Additionally, the record indicates that this provider is not in-network with the Plan. Therefore, we decided that the Plan does not have to pre-approve a CPAP cleaner and sanitizing machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System. You asked the Plan to pre-approve a continuous glucose monitor. You say that you cannot test on one of your hands and it hurts to be constantly testing on only 2 fingers. The Plan denied your request. The Plan says you are not insulin treated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. You are not insulin treated so you do not meet the Medicare coverage criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower denture reline (D5731) provided on February 4, 2020.You asked the Plan to pay for the dental service. You say that you have been unable to eat without pain for some time now. You say that your dentist recommended implants, but you do not have money for those. You say that your dentist also could do a soft reline that would help. You also say that no one informed you that only the top or bottom would be covered per year.The Plan denied your request. The Plan says the denture reline, upper or lower, is covered once per calendar year. The Plan also says the frequency limit for this benefit has been exhausted.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 denture relines are a covered service, the frequency limit for this benefit has been exhausted. The record shows that the Plan already paid for an upper denture reline that you received on February 4, 2020.Therefore, we decided that the Plan does not have to pay for the lower denture reline (D5731) provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of pulmonary artery monitor and sensor (33289, C2641). You asked the Plan to pre-approve insertion of pulmonary artery monitor and sensor. You say that the hemodynamic data are used by physicians for heart failure management and with the goal of reducing heart failure hospitalizations. The Plan denied your request. The Plan says this procedure is considered experimental and investigational and therefore not medically necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of pulmonary artery monitor and sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of pulmonary artery monitor and sensor (33289, C2641).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) and occupational therapy (OT) visits.You asked the Plan to pre-approve PT and OT visits. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PT and OT visits have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established.Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) and occupational therapy (OT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral sleep apnea device.
You asked the Plan to pre-approve the oral sleep apnea device. The Plan denied your request. The Plan says the
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider,
which requires prior authorization from the plan
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 oral sleep apnea device. We found no exception that would require the Plan to
pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an oral sleep apnea
device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear (L3260 and L3580). You asked the Plan to pre-approve the footwear. You say that you would like reconsideration because you are going to have surgery and this footwear will benefit your recovery.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear (L3260 and L3580).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro powered upper limb orthosis (L8701) to be provided by an out-of-network provider.You asked the Plan to pre-approve the orthosis. You say that you request reconsideration for approval of benefits for a custom, myoelectric elbow, wrist, hand orthosis to be provided by your clinical staff.The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness.The Plan must follow Medicare rules. Medicare rules say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approve the MyoPro powered upper limb orthosis (L8701) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 9, 2020. 
 
You asked the Plan to pay for the dental service. You say that the Summary of Dental Benefits says covered dental x-rays include 1 full mouth or panoramic x-ray and 1 set of bitewing x-rays each year and up to 7 periapical images per calendar year. You also say that the Preventive Dental Package is the package that was sold to you. The Plan denied your request. The Plan says you did not elect to purchase the optional supplemental dental benefit. The Plan also says that bitewing x-rays are not a covered service under your dental coverage. 
 
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 bitewing x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing xrays (D0274) provided on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for continuous passive motion exercise device
for use on knee only (E0935) provided from January 14, 2020 through February 2, 2020 by an in-network
provider.
You asked the Plan to waive the coinsurance for the DME. You say that you were under the influence of
medications and were lead to believe you would not be charged because it was part of the hospital stay. The
Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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).
Review of the file show that you received DME provided from January 14, 2020 through February 2, 2020 by
an in-network provider. You are asked to pay 20% coinsurance for the DME. Your EOC states, enrollees must
pay 20% coinsurance for in-network Medicare-covered DME and related supplies. 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 continuous passive motion exercise device for use on knee only (E0935) provided
from January 14, 2020 through February 2, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided from January 28, 2020 to February 18, 2020.You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says you must use a contracted and/or approved provider or supplier for the services to be covered and follow all rules for the benefit selected. 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 an alternative medicine network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for acupuncture services provided from January 28, 2020 to February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on December 12, 2019.
You asked the Plan to waive the copayment for the pacemaker evaluation. You say that you were seen by a technician and are being charged for a physician's visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for diagnostic procedures and tests. You have been asked to pay a $40 copayment for the pacemaker evaluation. The pacemaker evaluation falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were charged for the pacemaker evaluation which is considered a diagnostic test.
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 pacemaker evaluation provided on December 12, 2019.