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

We decided that the Plan does not have to pay for the installation of a walk-in shower.

You asked the Plan to pay for the installation of a walk-in shower. You say that this service was recommended by your physician. The Plan denied your request. The Plan says although a physician may suggest that home modifications may assist a member, these are not covered services. in addition, Medicare does not pay for walk-in bathtubs or showers.

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 pay for the installation of a walk-in shower.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95913, CPT 95886).

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.

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 95913 is "Nerve conduction studies; 13 or more studies".

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 use of CPT 95913 is not supported by the records provided. Our coding reviewer found that nerve conduction tests do not support 13 or more studies. If during a single study, the provider performs stimulation or recording of multiple sites on a single nerve, you should still count that as a single study.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 95913 have not been met.

Medicare rules also says that some codes in the "CPT Manual" are identified as "Add-on" Codes (AOCs), which describe a service that can only be reported in addition to a primary procedure. In this case, CPT code 95886 is an add-on code. As the primary CPT code 95913 is not covered in this case, the add-on code is also not covered. Therefore, we decided that the Plan does not have to pay for the services (CPT 95913, CPT 95886).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair (K0800) provided by an out of network (OON) provider.

You asked the Plan to pay for the power wheelchair. You say that when you called your Plan's customer service, they told you they would pay for 80% of it without mentioning that it had to be purchased within the Plan's network. The Plan denied your request. The Plan says they do not cover Durable Medical Equipment (DME) and related supplies that are purchased out of network. The Plan also says they investigated the customer service call and found that you were told that a prior authorization was required if the cost of the wheelchair exceeded $500. In addition, the provider confirmed that they did not refer you to any specific provider to obtain the wheelchair.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the power wheelchair (K0800) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (74019, R0070, Q0092) provided by an out of network (OON) provider.

You asked the Plan to pay for the radiology services. You say that you would like the Plan to pay for the services. The Plan denied your request. The Plan says the member does not have an out of network benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the radiology services (74019, R0070, Q0092) provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the colonoscopy services.

You asked the Plan to waive the cost share for the services provided. You say that the colonoscopy was
recommended as part of preventive care. The Plan denied your request. The Plan says the claim processed
correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 30%
coinsurance for each covered surgery in an outpatient hospital.

The file shows that you received a colonoscopy with a specimen removal. This is considered a surgical
procedure. You have been asked to pay a 30% coinsurance for each covered surgery in an outpatient hospital.
The services fall within the outpatient surgery benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share
for the colonoscopy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered from a non-contracted provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one routine eye exam per calendar year from a contracted provider.

We looked at the file and the Plan's rules. The file shows that you received routine vision services from a provider that is not contracted with the Plan. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the enrollee needs inpatient rehabilitation before she can safely return home. The Plan denied your request. The Plan says the enrollee does not meet the medical criteria for coverage of SNF care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain.

You asked the Plan to pre-approve the brain MRI. You say that the enrollee has had migraines, so an MRI is necessary. The Plan denied your request. The Plan says there are no symptoms described which would warrant this imaging at this time.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the brain MRI. Our reviewer says that the requested MRI is not considered medically reasonable and necessary. Our physician reviewer found the enrollee was seen by the provider for follow-up regarding COVID-19 infection and a hospital visit due to a fall resulting in a finger fracture. She was seen again after her orthopedics consultation and reported migraine headaches. There was no specific clinical rationale for the requested MRI of the brain. The review indicates that the requested MRI of the brain is not medically reasonable or 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 the brain MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the x-ray services.

You asked the Plan to waive the copays for the services provided. You say that the copay should not apply to
both claims. The Plan denied your request. The Plan says you are contractually obligated to pay the copay.

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 $55
copay for each Medicare-covered standard x-ray and ultrasound.

The file shows that you received an x-ray of the low back. You have been asked to pay $52.02 for the x-ray.
Because the amount is less than the $55 copay, you were charged the lesser amount. You also received an x-ray
of the neck. You have been asked to pay $51.30 for the x-ray. Because the amount is less than the $55 copay,
you were charged the lesser amount.

We looked at the file and the rules. Your plan contract says that you pay a copay for each x-ray received. The
services fall within the outpatient diagnostic tests 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
copays for the x-ray services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion (Current Procedural Terminology (CPT) code 22869).

You asked the Plan to pre-approve the services. You say that you are in a lot of pain and cannot walk. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show safety and efficacy of the device.

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 Vertiflex Superion (Current Procedural Terminology (CPT) code 22869).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (82728, 80053, 82248, P9604, G0471) provided by an out of network (OON) provider.

You asked the Plan to pay for the lab services. You say that this enrollee resides in a skilled nursing facility that is contracted with this lab. The Plan denied your request. The Plan says they do not cover out of network care except in limited circumstances. These services were not urgent, and they were not pre-approved.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lab services (82728, 80053, 82248, P9604, G0471) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (HCPCS J3490 and J1955) provided to the enrollee.

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 the documentation does not support the units billed.

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 the denied codes is:

HCPCS J3490: 

Drugs administered other than oral method, chemotherapy drugs

HCPCS J1955: 

injection, levocarnitine, per 1g

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 case were not supported by the medical records. Our physician reviewer found procedure codes J3490-59 (8 units, vitamin b6) and J1955 (4 units, levocarnitine) for services were submitted. Only one unit is supported for this code. No documentation was provided regarding the dose and medication administered on that day. As the injections were compounded, the code J3490 would be more appropriate instead of J1955. The dose of levocarnitive was not documented to verify the units administered.

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 pay for injection services (HCPCS J3490 and J1955) provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan.

You asked the Plan to waive the copay for the CT scan. You say that the services were needed to plan your surgery. The Plan denied your request. The Plan says the claim was processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 copay for CT scans.

You have been asked to pay $239.15 for the CT scan. Because the amount is less than the $375 copay, you were charged the lesser amount. The CT scan falls within the outpatient diagnostic tests 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 copay for the computed tomography (CT) scan.
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 covered.

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 you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that your insulin regimen does not require frequent adjustment on the basis of blood glucose levels or CGM testing results. The criteria for coverage are not met and the CGM is therefore 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for inpatient services.

You asked the Plan to pay for the inpatient services. You say that you would like reconsideration because this was an inpatient only procedure which was authorized by the Plan. The Plan denied your request. The Plan says that the facility did not notify the Plan within 24 hours of the member's admission.

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. we requested evidence of the authorization for this inpatient service from the Plan. The Plan failed to verify whether this service was authorized or forward the authorization. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for inpatient services.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for your gym membership fees.

You asked the Plan to pay for the gym membership fees. You say that you would like reconsideration because you paid for a three year membership and should be reimbursed per your Plan benefits. The Plan denied your request. The Plan says you have not submitted proof that you paid for a three year membership.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits after you submit an itemized receipt or other proof of payment.

The Plan's rules for coverage of gym benefits have not been met because the record does not include a receipt showing your payment to the gym. Therefore, we decided that the Plan does not have to pay for your gym membership fees.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99214).

You asked the Plan to waive the copayment for a specialist office visit. You say that you were never seen by
the physician and you should not be billed. The Plan denied your request. The Plan says the medical records
document that you were seen on the date of service.

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 $30
copayment for physician/practitioner services.

You have been asked to pay a $30 copayment for a specialist office visit. The service at issue falls within the
physician/practitioner 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 copayment for a
specialist office visit (99214).