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

We decided that the Planhasto pre-approve continued use of a CPAP machine for the enrollee.You asked the Planto pre-approvethe machine. You say that this is medically necessary.The Plandenied your request. The Plansaysthatas of 12/31/19, the enrollee is no longer enrolled in a benefit plan, and has since enrolled with a different provider.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 the machine. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found criteria for continued coverage of CPAP are met. This enrollee has OSA, on CPAP. 
The enrollee received a new device. There is documentation of a clinical follow-up visit and device usage meets criteria. CPAP is medically necessary for this enrollee.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 machine havebeen met.Therefore, we decided that the Planhas to pre-approvecontinued use of a CPAP machine for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies (A4253, A4259, A4256 and A4235) provided on July 23, 2019 through October 11, 2019.
You asked the Plan to pay for the diabetic supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid Proof of Delivery for the supplies provided in this case. The Proof of Delivery does not include an order number or itemization to indicate specific supplies. Therefore, we decided that the Plan does not have to pay for diabetic supplies (A4253, A4259, A4256 and A4235) provided on July 23, 2019 through October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the spinal fusion stimulator provided on July 30, 2019.
You asked the Plan to waive the coinsurance for the spinal fusion stimulator. You say that you were told the stimulator was approved and would be covered by insurance. 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 20% coinsurance for Medicare-covered benefits. You have been asked to pay $416.69 which is 20% of the allowed amount for the spinal fusion stimulator. The allowed amount is $2,083.47. ($2,083.47 x 20% = $416.69). The spinal fusion stimulator falls within the "Durable Medical Equipment (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 the spinal fusion stimulator provided on July 30, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency services (CPT 99282) provided to the enrollee on March 14, 2018.
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 two units of CPT 99282 were billed on the same day and the same revenue code without condition code G0.
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 99282 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity." We asked our coding 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 reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the case file does not appear to contain medical records for the services in question. The case file does show that 99282 was reported twice for the same date of service. According to NCCI MUE rules, 99282 has an MUE of 1. It cannot be verified that the bypass modifier reported is correct. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency services (CPT 99282) provided to the enrollee on March 14, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forinpatient mental health services provided to the enrollee from June 4, 2019 to June 10, 2019.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe dates of service remain denied, as they do not meet the medical necessity criteria for the services.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 reviewer says that the services at issue in this casewere not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, the admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in questionof June 7, 2019 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment.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 not been met.Therefore, we decided that the Plandoes not haveto pay forinpatient mental health services provided to the enrollee from June 4, 2019 to June 10, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 6, 2019 through September 8, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 6, 2019 through September 8, 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 forlumbar-sacral orthosis (L0648) provided to the enrollee on July 17, 2019.You asked the Plan to pay forthe orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the plan was unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not containevidence of a prior Telemedicine or Telehealth service with the ordering physician as requiredper 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 forlumbar-sacral orthosis (L0648) provided to the enrollee on July 17, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the $150 Dental Allowance for the prophylaxis (D1110) provided on February 12, 2019.
You asked the Plan to reimburse the $150 Dental Allowance for the dental services. You say that you have never received anything for this benefit. You also say that you should receive the full amount of the benefit. The Plan denied your request. The Plan says you were issued a check for $150 toward your out of pocket cost for dental services that you received on February 12, 2019. The Plan says the denial letter was for the additional $35 over the $150 benefit limit. The Plan also says that you were already reimbursed the full $150 Dental Allowance.
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 full $150 Dental Allowance reimbursement has already been issued. The record shows that the reimbursement check was issued on September 27, 2019. Therefore, we decided that the Plan does not have to reimburse the $150 Dental Allowance for the prophylaxis (D1110) provided on February 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 23, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you have a diabetes diagnosis. You say that you should have no copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each in-network Medicare-covered visit for medically necessary foot care.
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Podiatry Services" benefit category. The records show that you were treated for ingrown toenails, which is not considered a routine visit. 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 office visit provided on September 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe diagnostic digital breast tomosynthesis provided on July 1, 2019 billed with code 77062.You asked the Planto pay forthe breast tomosynthesis imaging. You say that this was incorrectly denied as duplicate but the report shows that this code should be paid.The Plandenied your request. The Plansaysthis code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must bill using the correct CPT code. The rules also say that the code G0279 is used for reporting digital breast tomosynthesis.CPT code 77062 has a status indicator of "I" in the Physician Fee Schedule. This means that it is invalid for Medicare billing purposes.Therefore, we decided that the Plandoes not haveto pay forthe diagnostic digital breast tomosynthesis provided on July 1, 2019 billed with code 77062
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.You asked the Plan to pre-approveTTE testing. You say that the enrollee is having palpitations.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there was no Holter monitoring or electrocardiogram (EKG) evidence of palpitations, and no other cited diagnostic indication for this test.The Plan follows Medicare rules. Medicare rules say that TTE testing may be useful in the evaluation of arrhythmias and palpitations, but palpitations without evidence of arrhythmias or minor arrhythmias without evidence of heart disease are not covered indications for TTE testing.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct indenying the request to pre-approve TTE testing. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested TTE test. Our physician reviewer found the enrollee reported palpitations. Physical examination documented a normal cardiac examination. Documentation does not include an electrocardiogram or differential diagnosis. Therefore, medical necessity cannot be determined for this request at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTE testing have not been met.Therefore, we decided that the Plan does not have to pre-approvetransthoracic echocardiography (TTE) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for wound care provided on June 27, 2019 and
September 2, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 for wound care provided on June 27, 2019 and September 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve(CPT Code E2377), (CPT Code E2313) and (CPT Code E2311).
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.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 DME have not been met. We see that a power wheelchair has recently been approved for you. Upgraded electronics (electronic connection, expandable controller and harness) cannot be covered per Medicare rules. They are necessary when there is a medical need to control power options though the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. More information will be given to your wheelchair provider.E2311 Electronic connection, E2377 Expandable Controller and E2313 Expandable Controller Harness have been denied and are appealed. E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt, recline and power elevating leg rests through the joystick. The notes state that these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. Documentation shows that the member has 4+ to 5/5 strength in the bilateral upper limb with intact range of motion. Member is able to performstraight catheterization independently. This upper limb strength and function is adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.Therefore, we decided that the Plan does not have to pre-approve(CPT Code E2377), (CPT Code E2313) and (CPT Code E2311
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis (74177).
You asked the Plan to pre-approve a CT of the abdomen and pelvis. You say that you are in pain and need to be evaluated. The Plan denied your request. The Plan says your needs could be met with an ultrasound.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT of the abdomen and pelvis. Our reviewer says that a CT is not medically necessary at this time. Our physician reviewer found there is evidence from prior CT in October, 2019 of a seroma in the left infraumbilical region likely resulting from abdominoplasty 16 years prior. There was no report of a wound, discharge, pain, or other complaint, and no findings on examination to suggest it was growing or changing. An ultrasound was reported to have been completed in the recent past to evaluate this area, but findings were not provided. There was no justification made for not repeating the ultrasound which would be most appropriate for evaluating a possible seroma. There was no evidence to show a more complex clinical situation to warrant CT scan. Therefore, this request for CT scan is not considered medically necessary at this time. 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 CT of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis (74177).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT codes L3916-LT, L3916-RT, and L0650 provided on September 3, 2019.You asked the Plan to pay forCPT codes L3916-LT, L3916-RT, and L0650. 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 for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary'smedical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The file shows that the enrollee received the same items L3916-LT, L3916-RT, and L0650 from different providers on dates of serviceJuly 27, 2017 and March 29, 2017. These are prior to the 5 years which Medicare determines is the reasonable useful lifetime for these items. The file does not contain any documentation showing that the replacement of these items was due to loss or irreparable damage.Therefore, we decided that the Plan does not have to pay forCPT codes L3916-LT, L3916-RT, and L0650 provided on September 3, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 18, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you requested a preventive checkup. You say that you should pay nothing for preventive care. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 for Medicare-covered laboratory tests. You have been asked to pay $14.88, which is less than the standard $20 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided on September 18, 2019.