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

We decided that the Plan does not have to pay for electrodes, per pair (A4556) provided October 13, 2018 to July 28, 2019.
You asked the Plan to pay for electrodes, per pair. You say that all A4556 are for 28 electrodes issued monthly. Please see attached script from referring provider. The Plan denied your request. The Plan says the provider has failed to submit correct claims with valid HCPCS codes.
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 A4556 is electrodes, per pair. These claims were not submitted with the appropriate HCPCS required by Medicare to indicate the TENS supplies. Based on this information, we decided that Medicare rules for coverage of electrodes, per pair have not been met. Therefore,
we decided that the Plan does not have to pay for electrodes, per pair (A4556) provided October 13, 2018 to July 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a left knee orthosis (L1851-LT) and a left suspension sleeve (L2397-LT) provided to the enrollee on March 8, 2019.
You asked the Plan to pay for the orthosis and sleeve. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported in the medical records received. The encounter appears to be a Telehealth service encounter however Telehealth guidelines 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 pay for the orthosis and sleeve. Our reviewer says that the documentation does not support that the durable medical equipment is medically necessary for this enrollee. Our physician reviewer found the enrollee's chief complaints were back pain and knee pain. The documentation in the case file does not support that the requested left knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. An appropriate physical examination of the knee would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the left knee orthosis and sleeve were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the knee. 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 orthosis and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a left knee orthosis (L1851-LT) and a left suspension sleeve (L2397-LT) provided to the enrollee on March 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a chronic obstructive pulmonary disease exacerbation. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee need vent weaning, daily labs, and aggressive rehab therapy.The Plan denied your request. The Plan says the enrolleeis receiving appropriate inpatient acute care, and does not require transfer.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH), having initially been admitted for pneumonia in the setting of gastric cancer. The enrollee was intubated/ventilated. He suffered a cardiac arrest and rupture of an aortic aneurysm. he eventually received a tracheotomy. The enrollee is tolerating the ventilator being on spontaneous mode. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 admission to an IRF does not meet criteria. Our physician reviewer found the member was admitted for acute care on 02/12/2020 with slurring of speech. Shewas found to be in atrial fibrillation and TPA was administered. She had previously been on warfarin which had been stopped 2 weeks ago. She is currently being treated with Eliquis. She has a normal body mass index. Her relevant past medical history includes hypertension and congestive heart failure. The member lives alone in a two-level residence with 10 steps to the entrance and 1 flight of interior steps and had been independent. Functionally, the member requires standby assistance for bed mobility and up to minimal assistance when transitioning from seated to standing and ambulating 90 feet x 2. She requires minimal assistance for grooming, toileting, and toilet transfers. The member is status-post stroke as described above. The member's medical conditions appear stable. There are no wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. Speech therapy is indicated for treating any ongoing impairments of communication. However, she is ambulating greater than household distances with minimal assistance and does not require an intensive rehabilitation therapy program. The member's medical conditions appear stable and she is participating in the treatments being provided. She would be expected to be able to fully participate and benefit from the required intensity of an acute rehabilitation therapy program. There isno reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level.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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 6, 2018.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare-covered trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered trip 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 ambulance transport provided on August 6, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemolar tooth nerve canal repair (D3348 x 2).You asked the Plan to pre-approvemolar tooth nerve canal repair (D3348 x 2). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested dental service (D3348) is not covered by Medicare or the Plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested molar tooth nerve canal repair (D3348) is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvemolar tooth nerve canal repair (D3348 x 2).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 1, 2017 to December 31, 2017.
You asked the Plan to pay for the skilled nursing services. You say that these services were medical because of the enrollee's diagnoses. The Plan denied your request. The Plan says this provider is not certified with Medicare and therefore, the services are not covered by the Plan.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from February 1, 2017 to December 31, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the batteries for the POV (K0108).
You asked the Plan to pre-approve batteries (K0108) for the POV. You say that you need the equipment. The Plan denied your request. The Plan says the Medicare coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that batteries are included in the cost of the POV and are not separately payable. Therefore, we decided that the Plan does not have to pre-approve the batteries for the POV (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forremoval of a tumor (17312, 17311), and repairing a wound (13132) provided on October 23,2019 by an out of network (OON) provider.You asked the Plan to pay fortumor removal and wound repair. You say that you went to Oregon and werediagnosed with cancer. You had emergency surgery to remove the cancer. You want to appeal this claim as you weren't home to receive the service.The Plan denied your request. The Plan says the claim for an out-of-network provider was denied as services were non-emergent or urgent.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, outof area urgent care and pre-approved care.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. 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 forremoval of a tumor (17312, 17311), and repairing a wound (13132) provided on October 23, 2019 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 foranesthesia provided on August 22, 2019.You asked the Plan to waive thecoinsurance foranesthesia. You say that you were informed the provider was in-network. You say that you were informed a routine colonoscopy was covered 100%.The Plan denied your request. The Plan says the coinsurance 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 30% coinsurance for provider and professional services at an out-of-network outpatient hospital.You have been asked to pay $19.01, which is 30% of the allowed amount for the anesthesia. The allowed amount is $63.36 (30% x $63.36 = $19.010. Anesthesia falls within the "Outpatient surgery, includingservices 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 coinsurance foranesthesia provided on August 22, 2019.Please note, this decision is only for the anesthesia provided on August 22, 2019. Contact the Plan directly regarding other services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a lower extremity arterial assessment provided on July 24, 2019.You asked the Plan to pay for the lower extremity arterial assessment. You say that this servicewas ordered by your primary care physicianand this service was medically necessary. The Plan denied your request. The Plan says you 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 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 caseand the ordering physician are notnetwork providerswith the Plan. The Plan did not pre-approve the servicesat 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 a lower extremity arterial assessment providedon July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor and appliance (E0652 and E0667).
You asked the Plan to pre-approve the pneumatic compressor and appliance. You say that the pneumatic compressor is medically necessary. The Plan denied your request. The Plan says the member has not had a four-week trial of a non-segmental compression pump (E0651 or E0650).
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 pneumatic compressor and appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records do not document that the member has had a four week trial of an E0650 or E0651 (a non-segmental compression pump). 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 pneumatic compressor and appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor and appliance (E0652 and E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on October 14, 2019.
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says criteria for the orthoses have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the removal of the torus mandibularis (D7473) for the lower left and lower right quadrants provided on September 18, 2019.
You asked the Plan to reimburse you for the dental services. The Plan denied your request. The Plan says the removal of the torus mandibularis is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the removal of torus mandibularis is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the removal of the torus mandibularis (D7473) for the lower left and lower right quadrants provided on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212) for teeth # 24, 25, and 26.You asked the Plan to pre-approve the dental services. You say that you spoke to a Plan representative on January 7, 2020 who advised that the partial was covered at 50%. You also say that the book states that bridges are covered.The Plan denied your request. The Plan says the mandibular partial denture is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, a mandibular partial denture is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5212) for teeth # 24, 25, and 26.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armodafinil for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this because of sleep apnea. The Plan denied your request. The Plan says that this medication is not covered under Part B.
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 pre-approve Armodafinil for the enrollee.
Benefits for this drug 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 11, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this will cause you a financial hardship. The Plan denied your request. The Plan says that copayments are a member's contractual obligation.
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 a $200 copayment for per one-way ambulance trip. The enrollee has been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way ambulance trip 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 the ambulance transport provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you have swelling in your arms and
edema. The Plan denied your request. The Plan says gradient compression stockings A6549 are non-covered
because they do not fit the definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.