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

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that the enrollee needs a Group 3 power wheelchair and accessories.The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services for a second opinion consultation.
You asked the Plan to pre-approve the physician's services for a second opinion consultation. The Plan denied your request. The Plan says the services must be emergent or not available within the medical group network in order to use a non-contracted 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services for a second opinion consultation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 27, 2019 to December 30, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not provided with a choice for a semi-private room 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 $230 copayment per day for days 1-7 for inpatient hospital care. You have been asked to pay $460.00 which is less than the total copayment amount for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from December 27, 2019 to December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diabetic shoes to be provided by an out of network provider.You asked the Plan to pre-approve the diabetic shoes. You say that the enrollee needs the diabetic shoes.The Plan denied your request. The Plan says in network providers can bill for the diabetic shoes.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 the diabetic shoes to be provided by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 11, 2019 by an out of network (OON) 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 an out-of-network 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 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 for the medical services provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided on April 10, 2019 by an out of network (OON) provider.You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.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 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 for the genetic testing services provided on April 10, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided March 29, 2019 to April 3, 2019.
You asked the Plan to waive the copayment for the inpatient care. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
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 per day copayment for days 1-5 for inpatient hospital services. You have been asked to pay a $800 copayment for 4 days of inpatient care. 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 inpatient hospital care provided March 29, 2019 to April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high frequency chest wall oscillation device (E0483).
You asked the Plan to pre-approve high frequency chest wall oscillation device. You say that the enrollee's
doctor has prescribed this for lifetime usage and considers it to be medically necessary. The enrollee has a
diagnosis of COPD and has a need for airway clearance. The Plan denied your request. The Plan says COPD in
the absence of a confirmed diagnosis of bronchiectasis do not meet the criteria.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease.
This means that you do not have a medical condition for which a high frequency chest wall oscillation devise
can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve high
frequency chest wall oscillation device (E0483).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on January 22, 2020, February 3, 2020,
February 10, 2020 and February 14, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the physical therapy services. 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 physical therapy services provided on January 22, 2020, February 3, 2020, February 10, 2020 and February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99153 provided on December 29, 2019.
You asked the Plan to pay for CPT code 99153. 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 providers must report services correctly.
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided
represent professional charges; however, procedure code 99153 was provided in a facility with a place of
service code of 23. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical
Component only code. Therefore, we decided that the Plan does not have to pay for CPT code 99153 provided
on December 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 8, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, 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 case is not a 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 physician's services provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 30, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0261).You asked the Plan to pre-approve the semi-electric hospital bed. You say that you are obese and have congestive heart failure. You have no feeling and cannot lift up your left leg due to a blood clot. You do not want to go back to a nursing home.The Plan denied your request. The Plan says based on the medical records provided the enrollee does not meet medical necessity criteria.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not indicate the enrollee has conditions that warrant immediate and/or frequent body position changes, or a need for special attachments that cannot be fixed to an ordinary bed.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 semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0261).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve functional electrical stimulation treatment (E0770).You asked the Plan to pre-approve functional electrical stimulation treatment. You say that the item is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, medical necessity has not been met.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 functional electrical stimulation treatment. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records, the enrollee's need for Bioness L300 Go system for electrical stimulation is not well founded and does not meet the criteria for medical necessity. There is no demonstration of a physical therapy (PT) or occupational therapy (OT) assessment in the record for which she was referred to PT and OT for braces evaluation. The long lengthy screening and support letter by the PT for the Bioness L300 Go system does not replace a good evaluation by the therapist and a trial of gait training with other means prior to jumping into an electrical stimulation device which is not typically provided for the diagnosis of spastic cerebral palsy with gait abnormalities.We looked at this physician's review, the file, and Medicare rules. Based on this information,we decided that Medicare rules for coverage of functional electrical stimulation treatment have not been met.Therefore, we decided that the Plan does not have to pre-approve functional electrical stimulation treatment (E0770).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml subcutaneous syringe (J0897).
You asked the Plan to pre-approve Prolia 60mg/ml subcutaneous syringe. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia 60mg/ml subcutaneous syringe. Our reviewer says that the medication is not medically necessary. Our physician reviewer found although the enrollee is not a candidate for oral bisphosphonate therapy due to their gastroesophageal reflux disease and Barrett's esophagus, the provided medical records do not indicate that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Zoledronic acid is contraindicated with a glomerular filtration rate of less than 35 mL/min. The enrollee has an estimated glomerular filtration rate of 48 mL/min based on laboratory testing of March 2, 2020. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia 60mg/ml subcutaneous syringe have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg/ml subcutaneous syringe (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the requested incontinence supplies are medically necessary for the enrollee. You say that the enrollee is going through her current supply very quickly. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture for chronic low back pain (CLBP).
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and has had multiple spine and hip surgeries. He has failed back surgery syndrome and the pain is likely related to his prior surgery and is not "non-specific." The Medicare rules exclude the use of acupuncture for CLBP that is associated with surgery; therefore, the services do not meet the criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture for chronic low back pain (CLBP).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker (E1399) provided on January 15, 2020 by an out of network (OON) provider. You asked the Plan to pay for the walker. You say that the walker was medically necessary. The Plan denied your request. The Plan says DME purchased from out-of-network suppliers is not covered. 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 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 for the walker (E1399) provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on December 3, 2019.
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 are not payable.
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every
HCPCS code.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99202 (office
visit) under the Hospital Outpatient Prospective Payment System (OPPS). This code has a status indicator of B
under the OPPS and is not payable. Therefore, we decided that the Plan does not have to pay for the office visit
rendered on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intravenous infusions provided from October 24, 2019 to October 29, 2019.You asked the Plan to waive the copayments for intravenous infusions. You say that you 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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received intravenous infusions from October 24, 2019 to October 29, 2019 for a total of 6 visits. Therefore, you are responsible to pay the total allowed mount of $1,066.32, which is less than the total copayment amount. You have been asked to pay $1,066.32 for intravenous infusions. Intravenous infusions fall within the outpatient surgery and other medical 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 intravenous infusions provided from October 24, 2019 to October 29, 2019