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

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided October 3, 2020.

You asked the Plan to pay for the orthoses. You say that you trust that the verification provided will be deemed sufficient to allow verification of the claims at issue. The Plan denied your request. The Plan says the supporting documentation does not match the information sent on the claim.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee did not meet the criteria needed for the orthoses provided. The enrollee did not receive a video or telephonic visit by the ordering physician to warrant the codes billed. There were no claims on file with the ordering physician listed in the enrollee's claims history. The Plan has also attested that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided October 3, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be handled 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of pneumonia, congestive heart failure, oxygen dependent COPD, and polyneuropathy living at home receiving home health services for weakness after recent skilled nursing stay. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on December 12, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you've never had to pay for MRI services in the past. You say that you don't owe this 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 $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $100 copayment for the MRI. The MRI 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 MRI provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0481) provided on August 11, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The service at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0481) provided on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 1, 2020.

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 procedure code 43235 is 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 43235 is esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).

We find that CPT code 43235 is not supported in the medical record. Specifically, there is no documentation that a diagnostic flexible EGD with collection of specimens was performed. 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 pay for the surgical services rendered on July 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on November 18, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you were told only one facility claim would be submitted so you would only have one copayment. The Plan denied your request. The Plan says you have been asked to pay 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 a $180 copayment per visit for other Medicare-covered services in a PCP or specialist office setting, urgent care facility, or a preferred (non-hospital based) radiological facility. You have been asked to pay a $180 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received MRI on a separate date of 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 the MRI provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the complete upper denture (D5110) provided on December 30, 2020.
You asked the Plan to pay the full amount for the dental item. You say that a plan representative advised you could go to this provider. You say that you were not informed about only one half of payment that you could get. You say that had you known, you would not have gone there. You also say that you believe that you are eligible for the full amount. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental items or services that you receive out of network are covered at 50% of the billed charge.
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 the dental item when the services are medically necessary and reasonable. 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 and complete upper denture is listed as a covered service, you are responsible for 50% of the billed amount for dental services performed out of network. Therefore, we decided that the Plan does not have to pay the full amount for the complete upper denture (D5110) provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5261) received January 31, 2021 from an out-of-network provider.

You asked the Plan to pay for the hearing aid. You say that the requested hearing aid was necessary. The Plan denied your request. The Plan says hearing aids received out-of-network are not covered by the Plan.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided through the Plan's Hearing provider. 

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261) received January 31, 2021 from an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 15, 2020 to October 29, 2020.
You asked the Plan to pay for home health services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not billed correctly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include a Q code to report the location in which the services were provided. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 15, 2020 to October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on November 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on November 12, 2020.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you told the provider's office that you only wanted services that would be covered by your plan. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the oxygen concentrator provided on February 21, 2021.

You asked the Plan to waive the deductible for the oxygen concentrator. You say that you want to know why nothing was paid. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Until you have paid the in-network deductible amount, you must pay the full cost of your covered in-network services. 

The item or service you asked the Plan to waive the deductible for falls within the "Durable medical equipment (DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 in-network deductible applies to durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the oxygen concentrator was received on January 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the oxygen concentrator provided on February 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for non-surgical management of a lumbar fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), preventive procedure (D1999), crown (D2740), and core buildup, including any pins when required (D2950) provided on August 31, 2020, and September 11, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation, preventive procedure, crown, and core buildup. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), preventive procedure (D1999), crown (D2740), and core buildup, including any pins when required (D2950) provided on August 31, 2020, and September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided on
July 12, 2020.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you returned this
because it was unwearable. The Plan denied your request. The Plan says the correct coinsurance has been
applied.
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%
coinsurance for durable medical equipment.
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The
total allowed amount is $2,925.60. The total amount you are being asked to pay is $585.12 ($2,925.60 x 20% =
$585.12). Since equipment was provided to you, the correct coinsurance has been applied. Durable medical
equipment falls within the durable medical equipment 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 durable medical equipment provided on July 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this device is covered by Medicare. The Plan denied your request. The Plan says Medicare criteria for reasonable and necessary are not met as it has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.

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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device remains experimental and more research is needed to show its safety and efficacy. 

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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from November 23, 2020, to November 26, 2020.
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from November 23, 2020, to November 26, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.