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

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are 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 pre-approve these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a diagnosis of Type 2 diabetes with other diabetic neurological complication. The note dated May 11, 2020 documents that he checks his blood glucose levels twice daily. The Medicare criteria of testing four or more times a day is not met; therefore, the CGM is not reasonable or medically necessary. 
 
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 a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies (A6250, A5120, T4535, T4528). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you cannot afford these supplies. The Plan denied your request. The Plan says these supplies are not covered under Medicare. 
 
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 (A6250, A5120, T4535, T4528).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator battery (E1357).
You asked the Plan to pre-approve a portable oxygen concentrator battery. You say that you do not currently
have a working battery for your oxygen concentrator. The Plan denied your request. The Plan says this cannot
be approved as requested.
The Plan must follow Medicare rules. Medicare rules say that all options, supplies and accessories are
considered included in the monthly rental payment for oxygen equipment. Oxygen rental is billed using the
appropriate code for the provided oxygen equipment. Separately billed options, accessories or supply items will
be denied as unbundling.
We looked at the file and Medicare rules. The requested item is bundled into the monthly rental payment for
oxygen equipment. It cannot be separately approved. Based on this information, we decided that Medicare
rules for coverage of a portable oxygen concentrator battery have not been met. Therefore, we decided that the
Plan does not have to pre-approve a portable oxygen concentrator battery (E1357).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (HCPCS L0650) provided to the enrollee on October 23, 2019.
You asked the Plan to pay for the orthosis. You say that this should be paid for. The Plan denied your request. The Plan says there is evidence of misrepresented services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code L0650 is "Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf." 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found based on the medical records provided documentation does not support the coding of a lumbo-sacral orthosis HCPCS L0650. The provided medical records do not document any evidence of an established relationship between the enrollee and the ordering physician. 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 have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (HCPCS L0650) provided to the enrollee on October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 17, 2018.
You asked the Plan to pay for the ambulance services. You say that the enrollee gave you the incorrect
insurance information. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the ambulance services was not filed until January 13, 2020. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the ambulance services provided on November 17, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) rendered by the out of network (OON) provider on January 15, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 outpatient diagnostic tests are not covered when provided out-of-network.  
 
The 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. 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 the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) rendered by the out of network (OON) provider on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery pack for a CPAP device. 
 
You asked the Plan to pre-approve the backup battery pack. You say that you would like reconsideration because your electricity often goes out. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
The file shows that you have a CPAP device. The power source for the CPAP device serves the same purpose as the backup battery pack. Therefore, we decided that the Plan does not have to pre-approve a backup battery pack for a CPAP device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on February 3, 2020. You asked the Plan to pay for the treatment of root canal obstruction. You say that your dentist told you that you needed a root canal and performed the procedure right away. You also say that you paid your copayment at the time of the procedure. The Plan denied your request. The Plan says this procedure is not a covered benefit. 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 27, 2020 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you need these tests done because of the medicine you are taking.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.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 physician services provided on January 27, 2020 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 for DME provided from August 30, 2019 to
September 30, 2019.
You asked the Plan to waive the coinsurance for DME. You say that you met the MOOP amount and disagree
with the additional 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 the MOOP amount for
2019 is $4,200. Your contract with the Plan also clearly says that you must pay 20% coinsurance for DME and
related supplies.
You received DME on August 30, 2019. The record shows that you had only paid $2,731.45 toward the $4,200
MOOP amount. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed
amount is $2,704.94 and 20% of that is $540.99.
You received DME on September 30, 2019. The record shows that you had only paid $3,906.23 toward the
$4,200 MOOP amount. Therefore, you are responsible to pay $293.77, which is less than the 20% coinsurance
amount.
The total amount you owe is: $834.76.
You have been asked to pay the total coinsurance amount of $834.76 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
August 30, 2019 to September 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 27, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for psychotherapy visit. You say that you are appealing with additional records. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider
is out-of-network with the Plan and the enrollee self-directed for service.
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 December 27,
2019 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 eye refraction (92015) provided on February 12, 2020. You asked the Plan to pay for the eye refraction (92015). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says eye refraction services are not covered by Medicare or the Plan when provided during a medical eye exam. The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar epidural (62323). You asked the Plan to pre-approve a lumbar epidural. You say that the lumbar epidural is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for the requested lumbar epidural. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 a lumbar epidural. Our reviewer says that the lumbar epidural is medically necessary. Our physician reviewer found the enrollee has chronic low back pain and has had 4 prior spine surgeries. He takes Aleve, Baclofen, Lyrica and oxycodone for pain. He has had Physical Therapy, Chiropractic therapy and a Home exercise program. He had 2 prior caudal epidural steroid injections. There is a clarifying letter which states he achieved greater than 50% pain relief after each injection and improved ambulation. The request is for another caudal epidural steroid injection. There is a clarifying letter which states he achieved at least 50% pain relief and improved ambulation after each Epidural steroid injection. The request is deemed medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar epidural have been met. Therefore, we decided that the Plan has to pre-approve a lumbar epidural (62323). 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 pre-approve an Inogen portable oxygen concentrator.
You asked the Plan to pre-approve an Inogen portable oxygen concentrator. You say that your current portable oxygen concentrator is too heavy. The Plan denied your request. The Plan says your current portable oxygen concentrator is meeting your in home oxygen needs and the suppliers say it is the lightest available.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. We looked at the file and Medicare rules. There is no documentation that your current portable oxygen concentrator is not meeting your in home needs. Based on this information, we decided that Medicare rules for coverage of a replacement portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator.
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 requested IRF care is medically reasonable and
necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically
reasonable and necessary based on Medicare guidelines.
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 is with a past medical history of diabetes, end stage renal disease,
hypertension, atrial fibrillation, congestive heart failure and peripheral arterial disease with gangrene of the
right lower extremity who presented to the acute hospital on 05/23/2020 with low blood pressure and altered
mental status after dialysis. She was treated in the emergency department with intravenous fluids and improved
but it was also discovered then that she had necrosis of her right foot (transmetatarsal amputation) necessitating
hospital admission. She underwent a right below the knee amputation on 05/26/2020 for gangrene. She requires
dialysis three times per week. She has a wound vac on the right lower extremity stump. She has had
Clostridium difficile colitis and is on vancomycin. She is weak and deconditioned and is working with physical
and occupational therapy. She is not walking and she is maximum assist for transfers and most activities of
daily living. She is medically stable for transfer. Transfer to an acute inpatient rehabilitation facility is
requested.
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does require skilled physical therapy and occupational therapy but based on the medical records
provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the
medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services (CPT 00540) provided to the enrollee on November
4, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says that the claim was processed correctly per how the provider billed the services.
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 00540 is "Anesthesia for thoracotomy procedures
involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy)."
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 services. Our reviewers says that the
services at issue in this case were coded correctly. Our physician reviewer found the codes billed (CPT code
00540 P3 QK and the CPT code 00540 P3 QX) were appropriately billed to document that the MDA was
medically directing the CRNA and the CRNA was providing anesthesia being medically directed by an MDA.
The records support that the codes were billed correctly. The claim was processed correctly and does not
appear to be a duplicate claim.
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 services have been met. Therefore, we decided that the Plan has to pay for
anesthesia services (CPT 00540) provided to the enrollee on November 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT Code S0207 provided on January 21, 2020.
You asked the Plan to pay for CPT code S0207. 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, CPT code S0207 has a status code of "I" under the
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have
to pay for CPT Code S0207 provided on January 21, 2020.