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

We decided that the Plan does not have to waive the copayment for the echocardiogram provided on December 11, 2019.
You asked the Plan to waive the copayment for the echocardiogram. You say that you were never informed that the services would come across as two bills. You say you cannot control how the hospital bills. The Plan denied your request. The Plan says the claim was reprocessed to reflect the correct $15 copayment.
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 $15 copayment for Medicare-covered non-radiological diagnostic test. You have been asked to pay a $15 copayment for the echocardiogram. The echocardiogram falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the echocardiogram provided on December 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on December 11, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that you need this to be waived because you are going through extreme financial hardship. The Plan denied your request. The Plan says you were charged this cost sharing 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 $225 copayment for covered ambulance services per day. You had 1 ambulance trip(s). The Plan charged you $225 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 17, 2019 to September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe debridement (11042). You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this provider is not in network and there is no authorization on file.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 forthe medical services provided on September 17, 2019 to September 24, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390).
You asked the Plan to pre-approve the DME. You say that you need oxygen, because at times you have difficulty breathing. The Plan denied your request. The Plan says the services are not 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 DME. Our physician reviewer found the record does not show that the oxygen is necessary based on the LCD.is necessary based on the LCD. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hemorrhoidectomy to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an OON hemorrhoidectomy. You say that you were told this provider was in-network.The Plan denied your request. The Plan says there are in-network providers available to perform this 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a hemorrhoidectomy to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCDhave not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from October 1, 2018 to October 5, 2018.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the copayment was applied correctly to the inpatient skilled nursing facility care 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 $0 copayment for days 1-20 and a $160 copayment for days 21-100, for each inpatient skilled nursing facility care stay. You have been asked to pay a $480 copayment ($160 x 3 days) for inpatient skilled nursing facility care provided for days 21-23 of your inpatient stay. 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 inpatient skilled nursing facility (SNF) care provided October 1, 2018 to October 5, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 15, 2019.You asked the Plan to pay for the orthoses and sleeves. You say that the claim should be paid.The Plan denied your request. The Plan says the medical records do not support this service.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 orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. The documentation does not support the diagnoses of Unilateral primary osteoarthritis of the right and left knees listed on the Physician's order. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeves have not been met.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 15, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled nursing visits (G0299).
You asked the Plan to pre-approve the home health services. You say that the home care is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the patient beyond what was approved by the health plan. There are no complex wounds or other complex skilled nursing need. The patient's needs are not so complex that they require the professional skills of a nurse to continue 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 the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 6, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The 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's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-area provider for physical therapy (PT).You asked the Plan to pre-approvethese services. You say that you will not be returning to the service area until mid-April and need to start PT.The Plan denied your request. The Plan says the servicesare not urgent or emergent and are available from in-area providers.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.We looked at the file and Medicare rules. The file shows that you left the Plan's service area with a chronic condition of sacroiliac (SI) joint dysfunction. The services are not being requested for an unforeseen illness or injury. The file shows that you will return to the Plan's service area in mid-April and can receive treatment from an in-area provider at that time. 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-approvea referral to an out-of-area provider for physical therapy (PT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore buildups, including any pins when required (D2950) for tooth #'s 30 & 31, periodontal maintenance (D4910), and crowns (D2750) for tooth #'s 30 & 31.You asked the Plan to pre-approvethe core buildups, periodontal maintenance, and crowns. You say that there is furcation involvement with the teeth in question but there is more than 50% bone support. You also say that teeth 30 &31 have cavities that need to be addressed.The Plan denied your request. The Plan says core buildup and periodontal maintenance are not covered services. The Plan also says that crowns are denied because there is bone decay around both teeth and there is not enough support.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. The Plan covers crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that the crowns are not medically necessary. Our physician reviewer found due to the poor prognosis resulting from the extent of recurrent caries and lack of periodontal support, crowns for tooth #'s 30 and 31 do not meet the criteria for coverage. We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Core buildup and periodontal maintenanceare not covered benefits. Therefore, we decided that the Plan does not have to pre-approvecore buildups, including any pins when required (D2950) for tooth #'s 30 & 31, periodontal maintenance (D4910), and crowns (D2750) for tooth #'s 30 & 31.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.You asked the Plan to pre-approvethese services. You say that you are concerned due to your CEA level.The Plan denied your request. The Plan says you do not meet the criteria for coverage.The Plan must follow Medicare rules.Medicare rules say that BRCA genetic testing is covered when there is a personal history of breast cancer (invasive breast cancer or ductal carcinoma in situ).We looked at the file and Medicare rules. The file shows that you do not have a personal history of breast cancer. 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-approveBRCA genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered standing lift (E1399).
You asked the Plan to pre-approve the stand lift. You say that the lift is medically necessary. The Plan denied your request. The Plan says the item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a powered standing lift (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were necessary. The Plan denied your request. The Plan says the care provided could have been accomplished at an observation level of care, therefore coverage criteria for inpatient admission has not been met.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 16, 2019 to November 17, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 5, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that you are unable to pay the bill. You say that you want assistance. 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 $200 for outpatient surgery and other procedures. You have been asked to pay a $200 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the endoscopy provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 16, 2019 by an out of network (OON) provider.
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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 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 the laboratory services provided on October 16, 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 knee brace and the addition to lower extremity orthosis provided on November 20, 2019.
You asked the Plan to pay for knee brace and the addition to lower extremity orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan follows Medicare rules. Medicare rules say that knee braces are only covered for certain indications. 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 knee brace and the addition to lower extremity orthosis. Our reviewer says that the documentation does not support that the items rendered were medically reasonable or necessary. Our physician reviewer found there were no submitted physician progress notes prior to the date the DME were provided to the enrollee indicating the patient's ambulatory status, evidence of objective knee instability or knee pathology on a physical exam that would require the DME in appeal. There was no discussion of the DME in appeal in a physician progress note prior to the DME being provided indicating this was part of the enrollee's treatment plan. Therefore, the enrollee did not meet criteria
for the items rendered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee brace and the addition to lower extremity orthosis have not been met. Therefore, we decided that the Plan does not have to pay for knee brace and the addition to lower extremity orthosis provided on November 20, 2019.