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

We decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT code(s) K0554) and supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553).
You asked the Plan to pre-approve the diabetic supplies. You say that you have not testing your sugars since January 2021. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 notes do not show you require insulin injections at least three (3) times per day or use an insulin pump and that you check your blood sugar levels four (4) or more times a day so this request has been denied. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT code(s) K0554) and supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 26, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 26, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on January 13, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records and have provided reason of medical necessity with the valid procedure and diagnosis codes listed. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
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. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on January 13, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient assisted living visit (99334) provided on
November 7, 2020, by an OON provider.
You asked the Plan to pay for established patient assisted living visit. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not
obtained for these services rendered by an OON 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 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 had network providers
available who could have provided 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 established patient assisted living visit (99334)
provided on November 7, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided from January 15, 2021, to
February 14, 2021.
You asked the Plan to waive the coinsurance for DME. 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 20%
coinsurance for DME and related supplies.
You received DME from January 15, 2021, to February 14, 2021. The total allowed amount is $164.40 and
20% of that is $32.88.
You have been asked to pay the total coinsurance amount of $32.88 for DME. DME falls within the DME and
related supplies 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 for DME provided from
January 15, 2021, to February 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive pharmacogenomic panel testing provided on July 23, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with additional documentation and should not be penalized for being out-of-network. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular/respiratory risk assessment panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab requisition form submitted does not show that the results of this testing were requested for the treatment or management of a specific medical condition. The testing at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for comprehensive pharmacogenomic panel testing provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services provided on February 4, 2021.
You asked the Plan to waive the copayment for the podiatry services. You say that you did not have any skin removed and did not have any lesions. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for Medicare-covered podiatry services.
You have been asked to pay a $40 copayment for the podiatry services. The podiatry services fall within the "Podiatry services" benefit category. The medical record shows that toenails 1-5 on both feet were debrided in length and thickness and all hyperkeratotic lesions were debrided with a 15 blade. 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 podiatry services provided on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive
interface, (e.g., mask, chest shell) (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that the Life 2000 is a portable ventilator assist
device designed for using when the enrollee is mobile and would be ideal to help this enrollee. The Plan denied
your request. The Plan says this is not covered by Medicare.
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 home ventilator have not been met. You prescribed a ventilator
to help the enrollee's breathing at various times of the day (night and day) because of the enrollee's lung
disease. Medicare does not cover ventilators used in this way. Medicare will cover a device called respiratory
assist device that as advanced features and the plan will cover this when medically necessary. Therefore, we
decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface,
(e.g., mask, chest shell) (CPT code E0466), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the knee brace provided on November 19, 2020.
You asked the Plan to waive the cost share for the knee brace. You say that the charges were not explained before you received the brace. The Plan denied your request. The Plan says the claim processed 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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance for the knee brace. The knee brace falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the knee brace provided on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenomic panel testing provided on July 15, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular/respiratory risk assessment panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for pharmacogenomic panel testing provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite (D2392) provided on November 2, 2020.
You asked the Plan to pay more for the resin-based composite. You say that you understood that the service would be covered. The Plan denied your request. The Plan says this service was processed up to the annual maximum benefit of $1,000. The Plan also says that after the annual maximum is exhausted, any remaining charges are your responsibility.
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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the November 2, 2020 date of service and your annual
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2392) provided on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided on October 14, 2020.
You asked the Plan to pay for the pneumatic compression device. 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 does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a chiropractor (99212) provided on December 18, 2020.
You asked the Plan to pay for an office visit with a chiropractor. You say that you would like reconsideration because you were not aware that this provider does not accept Medicare. The Plan denied your request. The Plan says coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit with a chiropractor (99212) provided on December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for fitness equipment provided on
December 14, 2020.
You asked the Plan to reimburse you for the fitness equipment. You say that you were informed by the Plan that it would be covered as an exception in 2020 due to the pandemic. The Plan denied your request. The Plan says fitness equipment was not part of the Wallet Benefit, or reimbursable under any benefit in the 2020 plan year. Although the Plan's Member Services Representative provided wrong information regarding an exception being made for fitness equipment reimbursements, this information was given to you after the item was purchased.
The Plan contract offers a supplemental Wallet Benefit. We looked at the file and the Plan's rules. The file shows that the Wallet Benefit does not cover reimbursement for fitness equipment. Therefore, we decided that the Plan does not have to reimburse you for fitness equipment provided on December 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a total knee arthroplasty revision (27487) and related services (C1776, 86850, 86900, 86901, 87070, 87075, 88300, 73560, 94760, 97161, 97165, J7030, J7050, J7120, J0171, J0690, J1170, J1885, J2250, J2274, J2370, J2406, J2704, J2795, J3010, J3370, J3475, A9270) provided from November 3, 2020, to November 4, 2020.
You asked the Plan to pay for a total knee arthroplasty revision and related services. You say that this was pre-approved as an outpatient service. The Plan denied your request. The Plan says this is an inpatient-only service.
The Plan must follow Medicare rules. Medicare rules say that Medicare generally does not pay for an "inpatient-only" service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type. Medicare also does not pay for all other services on the same day as the "inpatient only" procedure. We looked at the file and Medicare rules. The total knee arthroplasty revision (27487) at issue is designated as am inpatient-only procedure and therefore must be billed as part of an inpatient admission. Based on this information, we decided that Medicare rules for coverage of a total knee arthroplasty revision and related services have not been met. Therefore, we decided that the Plan does not have to pay for a total knee arthroplasty revision (27487) and related services (C1776, 86850, 86900, 86901, 87070, 87075, 88300, 73560, 94760, 97161, 97165, J7030, J7050, J7120, J0171, J0690, J1170, J1885, J2250, J2274, J2370, J2406, J2704, J2795, J3010, J3370, J3475, A9270) provided from November 3, 2020, to November 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 18,
2020, to December 21, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from December 18, 2020, to December 21,
2020.
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 IRF care is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says rules for IRF care have not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.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 that based on the documentation provided, 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three (3) additional urinary catheters per month (CPT code A4338).
You asked the Plan to pre-approve the catheters. You say that you are only able to get one catheter per month. You state you are paraplegic and require the catheters to live life. The Plan denied your request. The Plan says Medicare allows for one (1) urinary catheter per month unless your history shows an increased medical need such as history of recurrent obstruction or recurrent urinary tract infections. The Plan states your medical record does not document this.
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 catheters. Our physician reviewer found the review indicates Medicare allows for one (1) urinary catheter per month unless your history shows an increased medical need such as history of recurrent obstruction or recurrent urinary tract infections.
Review of the medical record did not document this. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage for additional catheters. 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 catheters have not been met. Therefore, we decided that the Plan does not have to pre-approve three (3) additional urinary catheters per month (CPT code A4338).