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

We decided that the Plan does not have to waive the copayments for strapping provided from December 4, 2020, to December 30, 2020.

You asked the Plan to waive the copayments for strapping. You say that you disagree with the surgery charges.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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities.You received strapping at an outpatient hospital facility from December 4, 2020, to December 30, 2020, for a total of 5 services.Therefore, you are responsible to pay the total allowed amount of $1,018.75, which is less than the total copayment amount.  

You have been asked to pay the total amount of $1,018.17 for strapping. Strapping 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 copayments for strapping provided from December 4, 2020, to December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs.

You asked the Plan to pre-approve the requested services. You say that the repair is needed due to normal wear and tear.The Plan denied your request. The Plan says the repairs cannot be covered.

The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess.

We looked at the file and Medicare rules. The records show that the total cost of repair for the enrollee's current wheelchair exceeds the estimated expense of replacing the wheelchair. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve a continuous glucose monitor. You say that you have not received any injections of insulin for over 11 months. You say that you have been paying out of pocket for diabetic supplies since May of 2020 because the medical group will not approve coverage. 

You say that you have about three weeks' worth of supplies and do not want to keep paying out of pocket.The Plan denied your request. The Plan says the records show that you are not under any insulin therapy; thus, not meeting criteria for a therapeutic continuous glucose monitor.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. 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 continuous glucose monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from October 5, 2020, through December 24, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you were never told you would be charged $40 per visit. You say that you would not have participated in therapy if you had been aware of the cost.The Plan denied your request. 

The Plan says the copayments 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 $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit. 

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $480 ($40/visit x 12 visits = $480). Physical therapy falls within the "Outpatient Rehabilitation 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 waive the copayment for physical therapy provided from October 5, 2020, through December 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 21, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that you were not injured you just needed help getting up. You say that you didn't need an ambulance, but one was sent.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 $250 for each non-Medicare-covered ambulance stabilization when there is no transport.

You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show you received treatment but no transport. 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 ambulance transport provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for antigen therapy services provided on July 21, 2020.

You asked the Plan to waive the copayment for antigen therapy services. You say that you did not got to the office on this date and disagree with the charges.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 $35 copayment for specialist visits. The medical records show that you received specialist services on July 21, 2020. 

Therefore, you are responsible to pay the allowed amount of $24.64, which is less than the $35 copayment. You have been asked to pay $24.64 for antigen therapy services. Antigen therapy services fall 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 antigen therapy services provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 19, 2021.

You asked the Plan to waive the copayment fora specialist visit. You say that you cannot afford the charges.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 $50 copayment for each specialist visit. 

You have been asked to pay a $50 copayment for a specialist visit. A specialist 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 a specialist visit provided on January 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on February 1,
2021.

You asked the Plan to waive the copayment for emergency care. You say that you have COVID-19 and do not
want to be charged every time you have to go to the emergency room. 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 $90
copayment for emergency care.

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency
care 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 emergency care provided on
February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laparoscopy provided on February 25,
2021.

You asked the Plan to waive the copayment for a laparoscopy. You say that you were told that you would only
owe a $90 copayment. 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 $200
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.

You have been asked to pay a $200 copayment for a laparoscopy. A laparoscopy 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 a laparoscopy provided on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical supplies to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve medical supplies. You say that this provider waives cost-sharing as part of their business model, and it is necessary for your financial survival. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because this provider is out-of-network with 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 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 medical supplies to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 24, 2020.

You asked the Plan to pay for the ambulance services. You say that the severity of your condition this service was necessary. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 24, 2020. 

The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 17 skilled nursing visits and 1 PT visit.

You asked the Plan to pre-approve the skilled nursing visits and PT visit. You say that you need these services
to be approved for coverage. The Plan denied your request. The Plan says the required documentation
requested to continue these services has not been received. The Plan also says that documentation that your
provider has reviewed the skilled nursing visit and physical therapy visit has not been received.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

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 skilled nursing visits and PT visit.
Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer
found the documentation does not support that you require additional skilled nursing services or additional
skilled rehab services to provide treatment that is medically necessary. Our reviewer found that you do not
require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in
order to improve your condition, perform a maintenance program to maintain your condition and/or prevent
deterioration. Our physician reviewer also found that you have been medically stable without any recent
exacerbations of chronic medical problems or hospitalizations.

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 skilled nursing visits and physical therapy visit have not been met.
Therefore, we decided that the Plan does not have to pre-approve 17 skilled nursing visits and 1 PT visit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nayzilam spray.

You asked the Plan to pre-approve Nayzilam spray. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for Medicare Part B drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nayzilam spray.

Benefits for Nayzilam spray 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the brand specific upright walker.

You asked the Plan to pre-approve the brand specific upright walker. You say that with a regular walker you have to bend over making you sore. The Plan denied your request. The Plan says this walker does not have a code assigned and the supplier is not Medicare certified.

The Plan must follow Medicare rules. The rules say that for equipment to be covered it must be purchased from a Medicare certified supplier. 

Although the requested brand of walker is considered to be durable medical equipment by Medicare's standards, it isn't a covered device. Because the walker's supplier doesn't accept Medicare, neither version of the walker is reimbursable through Traditional Medicare or Medicare Advantage benefits. Therefore, we decided that the Plan does not have to pre-approve the brand specific upright walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories.

You asked the Plan to pre-approve Group 3 power wheelchair. You say that you are appealing with supporting information to prove medical necessity. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this power wheelchair is not separately covered while the enrollee is a patient in a skilled nursing facility.

The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) such as a Group 3 power wheelchair is not separately covered by Medicare Part B if the enrollee is a patient in a skilled nursing facility. 

We looked at the file and Medicare rules. This enrollee is a patient in a skilled nursing facility; therefore, the requested Group 3 power wheelchair is not covered by Medicare in this setting. Based on this information, we decided that Medicare rules for coverage of Group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #4.

You asked the Plan to pre-approve the crown. You say that the enrollee needs this crown. The Plan denied your request. The Plan says placing a crown on tooth #4 in its current state is not recommended.

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. The Plan covers the crown when the services are medically necessary and reasonable.

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 crown. Our reviewer says that the requested service cannot be recommended. Our physician reviewer found this request is for a crown for tooth #4 which has previously had a root canal. The panoramic x-ray submitted demonstrates inadequate root canal fill. Our reviewer found that no other information is provided. Our physician reviewer also found that the elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #4.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a
Sanexas device reported on September 22, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You
say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan
says the record does not support that the procedures were performed 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.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression
or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is
application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The
HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals).
The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection
(specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code
J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection,
thiamine HCl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine HCl,
100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record.
Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer
of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the
criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was
applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code
97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed.
The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy
at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record
does not contain documentation of the dosage and type of drug administered in each injection, which is
required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections
and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to
pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 22,
2020.