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

We decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary for post-surgery 
recovery. The Plan denied your request. The Plan says there are no conditions that require a specific body 
position or adjustment. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the documentation doesn't support that you have a condition that requires frequent positioning of the bed and 
mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory infections in 
a way that an ordinary bed is not able to. 
 
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 Plan does not 
have to pre-approve a semi-electric hospital bed with mattress.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the microslide consultation represented by code 88321 provided on October 21, 2020.

You asked the Plan to pay for code 88321. 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for the microslide consultation represented by code 88321 provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OmniSeq Insight genetic panel for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says it has not been demonstrated that the number of genes in the panel is reasonable and 
necessary to obtain necessary information for therapeutic decision making. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the OmniSeq Insight panel (code 81455) is considered unlikely to impact therapeutic decision making. 
The enrollee had genetic testing already with Guardant, and it has not been demonstrated that the number of 
genes in the requested panel are reasonable and necessary to obtain necessary information for therapeutic 
decision making. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the OmniSeq Insight genetic panel for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the deductible for a cataract surgery provided on March 10, 2021.
You asked the Plan to waive the deductible for a cataract surgery. You say that you cannot afford the charges and ask that the deductible charges be removed. The Plan denied your request. The Plan says that the claims were processed correctly, and you are being charged the correct amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The provider codes listed on the claim do not indicate that services took place in a hospital facility. The Plan did not provide any information clearly showing that services took place within a hospital facility. Without this information we cannot determine whether the accurate cost-sharing was applied. Therefore, we decided that the Plan has to waive the deductible for a cataract surgery provided on March 10, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0821) for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a home assessment or a standard written order.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation is not consistent that the enrollee has a personal mobility deficit that impairs participation in MRADLs. The progress notes from May 2021 and June 2021 are conflicting on the enrollee's gait, noting both severe gait debility and normal gait. With a normal gait, it is not clear why the enrollee is not able to use a walker, cane, or manual wheelchair. There is no objective home evaluation indicating the enrollee can safely maneuver a power wheelchair in the home. 

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0821) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of blepharoptosis (67904) provided on March 10, 2021.
You asked the Plan to pay for the repair of blepharoptosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this procedure is cosmetic in nature and not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 repair of blepharoptosis. Our reviewer says that the record indicates that the enrollee underwent ptosis bilateral ptosis repair.
The provided medical records are insufficient to establish that the coverage criteria are satisfied. Our reviewer
found the requested service appears to be cosmetic in nature.
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 repair of blepharoptosis have not been met. Therefore, we decided that the
Plan does not have to pay for the repair of blepharoptosis (67904) provided on March 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided on February 3, 2021, and February 6, 2021.

You asked the Plan to waive the copayments for ambulance services. You say that you did not request the services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $240 copayment for ambulance services. 

You received ambulance services on February 3, 2021. Therefore, you are responsible to pay the allowed amount of $233.66, which is less than the $240 copayment.

You received ambulance services on February 6, 2021. Therefore, you are responsible to pay the $240 copayment. 

The total amount you owe is: $473.66. 

You have been asked to pay the total amount of $473.66 for ambulance services. Ambulance services fall 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 copayments for ambulance services provided on February 3, 2021, and February 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 26, 2021, by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the treating provider was requested to see the enrollee as an attending provider in an outpatient capacity. You also say that there is a medical necessity pre-established with the enrollee and the facility to be treated by this provider. The Plan denied your request. The Plan says prior authorization was not obtained.
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 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 subsequent nursing facility care provided on March 26, 2021, by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit with an orthopedist you had on April 1, 2021.

You asked the Plan to waive the copayment for the orthopedist visit. You say that this visit was a follow-up from surgery you had in November, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 specialist visits.

You have been asked to pay a $50 copayment for the orthopedist visit. Records show that you had surgery in November of 2020. According to Medicare rules, follow-up visits outside of the postoperative period are not included in the payment for the surgery itself and can be charged separately. In this case, you had a major surgery. Medicare rules state that the postoperative period for major surgeries is 90 days. Because the follow-up visit at issue in this appeal occurred outside of this 90-day period, the copayment for this specialist visit was charged appropriately. 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 visit with an orthopedist you had on April 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on December 18, 2020.
You asked the Plan to pay for the ambulance transport. You say that the patient is bed confined and required special isolation with transport due to being positive for coronavirus. You say that the patient did not have hospice and the claim should be reprocessed. The Plan denied your request.
The Plan says Original Medicare is responsible for payment.
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 the ambulance transport provided on December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says a trial of an E0471 device has not been undertaken.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has severe COPD that has been confirmed on pulmonary function testing. However, bilevel positive airway pressure (BiPAP) has not been tried. Certain BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode of support that has been ordered, and Medicare does not cover a home ventilator when used as BiPAP.
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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator for the enrollee
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychotherapy (90837) provided on
March 8, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.

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
copayment for each in-person outpatient mental health or outpatient psychiatric individual or group therapy
visit.

You have been asked to pay a $90 copayment for the in-person outpatient mental health visit provided. 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 psychotherapy (90837) provided on
March 8, 2021.
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 can tolerate and would benefit from the intensity of services provided at an IRF. The Plan denied your request. The Plan says the criteria for an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 the documentation does not support that the enrollee has the ability to tolerate intensive rehabilitation. The enrollee would benefit from speech, physical and occupational therapies, however,
with their current mental status, there is no evidence of a need for an intensive therapy program with three hours of therapy per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary in this case based on a lack of medical complexity other than psychiatric care and no identified rehab nursing needs. Functionally, it is not expected this enrollee would be able to participate or make progress at an IRF level of rehab. The enrollee's rehab needs can be safely met at a less intense and alternate 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide non-emergency transportation; taxi (A0100), greater than the 
Plan's 50-mile limit. 
 
You asked the Plan to provide routine transportation greater than the 50-mile limit. You say that the routine 
transportation is necessary. The Plan denied your request. The Plan says the trip distance is greater than 50 
miles one-way and therefore is not covered under your transportation benefit. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation within a 50-mile limit. 
 
We looked at your request, the records in the case file, and the rules. We verified that the distance of the 
requested trip is greater than 50 miles. Based on this information, we decided that the Plan's rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide non-
emergency transportation; taxi (A0100), greater than the Plan's 50-mile limit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82542, 83090, 83789) rendered by
the out-of-network (OON) provider on December 10, 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 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 laboratory services (82542,
83090, 83789) rendered by the out-of-network (OON) provider on December 10, 2020.