Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless foran office visit (99203) provided by "the doctor" on August 15, 2019.You asked the Plan to hold you harmless for an office visit. You say that you requested your primary doctor to be "the doctor". You gave that information to the registration desk. You say the information was ignored and another doctor was listed. Because of this mistake, you have been charged "out of network" for services.You request that this error be corrected.The Plan denied your request. The Plan says that according to your EOC, there is coverage for a specialist office visit. It states that a consultation, diagnosis, and treatment by a specialist does have a $25 copayment, but authorization may be required. According to your primary care physician's office you were not authorized to receive treatment from "the doctor". Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. "The plan" follows these rules.If a network physician furnishes a service or directs an Medicare Advantage beneficiary to another provider to receive a plan-covered service without following the plan's internal procedures (such as obtaining the appropriate plan pre-authorization), then the beneficiary should not be penalized to the extent the physician did not follow plan rules. You were referred for an office visit by "the doctor". "The doctor" is a contract provider. The file does not show that "the plan" provided notice that an office visit would not be covered.The services at issue were provided by "the doctor". Thecontract provider did not follow plan pre-authorization procedures and you should not be penalized.UnderMedicare rules, this means an office visit is considered approved by "the plan". Therefore, we decided that the Plan has to hold you harmless foran office visit (99203) provided by "the doctor" on August 15, 2019. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vascular procedure provided on April 3, 2019.
You asked the Plan to waive the copayment for the vascular procedure. You say that you did not any find charge of $275 that you should pay in the 2019 membership advantage book. You say this charge only applies to in-patient surgery and therefore you do not owe this amount. 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 $275 copayment for Medicare-covered in-network outpatient hospital services. You have been asked to pay a $275 copayment for the vascular procedure. The vascular procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the vascular procedure was performed as an outpatient procedure.
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 vascular procedure provided on April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified (CPT Code A9279) provided from June 1, 2019 through June 30, 2019.You asked the Plan to pay for the monitoring device. You say that the service should be paid for by the Plan because you were advised by your Case Manager that you should obtain thisservice.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the monitoring device have not been met. This monitoring device as billed is not a covered benefit under your plan. In addition, per the Centers for Medicare and Medicaid fee schedule, code A9279 for the monitoring feature device is not reimbursable.Therefore, we decided that the Plan does not have to pay formonitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified (CPT Code A9279) provided from June 1, 2019 through June 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for the enrollee.
You asked the Plan to pre-approve genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that genetic testing identified with code 81455 is non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 24, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were not transported. The Plan denied your request. The Plan says that your cost sharing 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 $230 copayment for Ambulance Services. You have been asked to pay less than a $230 copayment for the ambulance transport. The ambulance transport falls within the Ambulance 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 the ambulance transport provided on August 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on August 22, 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 orthosis 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 wrist hand orthosis (L3916). Our physician reviewer found the enrollee's chief complaint was wrist/hand pain on the right and left. Bilateral wrist/hand orthoses were ordered. The documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the wrists.
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 wrist hand orthosis (L3916) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided by August 7, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
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 non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided by August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 13, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says criteria for the orthoses 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 lumbar-sacral orthosis (L0650). Our
physician reviewer found the enrollee's chief complaint was back pain. The available documentation in the case
file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the
enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a
physical examination of the back would reasonably be required to adequately assess whether the coverage
criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral
orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of
a credible physical examination of the back.
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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided
that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1851) and
suspension sleeve (L2397) provided August 21, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of
medical necessity. The Plan denied your request. The Plan says the documentation does not identify the
enrollee's originating site at the time of the telehealth visit, there is no evidence of an established relationship
between the enrollee and the ordering physician, there was no claims submitted for an evaluation and
management service and there is no evidence of a prior telehealth service with the ordering physician as
required per CMS guidelines.
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 non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis
(L0650) knee orthosis (L1851) and suspension sleeve (L2397) provided August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on March 6, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary The Plan denied your request. The Plan says rules for telehealth services 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 lumbar-sacral orthosis
provided on March 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960) provided March 11, 2019.
You asked the Plan to pay for the SEWHO. You say that the records provided will show proof of medical necessity. The Plan denied your request. The Plan says the documentation did not include a valid physician order for the billed supply. There is no evidence of an established relationship between the enrollee and the ordering physician. There was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
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 shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960) provided March 11, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for the peripheral arterial disease rehabilitation visit provided on September 4, 2019.
You asked the Plan to waive the copayment for the peripheral arterial disease rehabilitation visit. You say that you will not pay the copayment for the day you were sent home from rehabilitation because your blood pressure was too high. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for cardiac rehabilitation services. The Plan says you must pay a $40 copayment for the peripheral arterial disease rehabilitation. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the peripheral arterial disease rehabilitation. The record shows that peripheral arterial disease rehabilitation is considered cardiovascular in nature. Therefore, we decided that the Plan has to waive the copayment for the peripheral arterial disease rehabilitation visit provided on September 4, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on March 26, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services 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 lumbar-sacral orthosis provided on March 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 16, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says criteria for the orthoses 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 lumbar-sacral orthosis (L0650). Our physician reviewer found the enrollee's chief complaint was back pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs physical therapy and will benefit from a higher level of care for these services. You say that the enrollee has a GI bleed and will be an excellent candidate for rehab. You say that the enrollee is just sitting the hospital and is ready for rehab. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.
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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on August 22, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says criteria for the orthoses 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 knee orthosis (L1851) and suspension sleeve (L2397). Our physician reviewer found the enrollee's chief complaint was chronic knee pain. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of a recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis (L1851) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on August 22, 2019.