Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health services.

You asked the Plan to pre-approve home health services. You say that this is medically necessary.The Plan denied your request. The Plan says that the diagnosis of pleurodynia is not a diagnosis that Medicare supports for medical necessity of these services.

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 home health services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is documentation that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Detailed review of the records clearly document multiple other diagnoses besides pleurodynia including unstable gait, multiple falls, rib fractures, patellar fracture and chronic obstructive pulmonary disease. The medical records with regard to these conditions clearly document medical necessity of home health physical and occupational therapy services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have been met.Therefore, we decided that the Plan has to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blood tests and cancer medicines during a clinical trial
for the enrollee.
You asked the Plan to pre-approve the services. You say that this approval is required to continue in the trials
group. The Plan denied your request. The Plan says routine costs due to a clinical trial are covered directly by
Medicare, and not the plan.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve the services as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove
blood tests and cancer medicines during a clinical trial for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora dental exam to evaluate a problem (D0140) provided on September 2, 2020.You asked the Plan to pay fora dental exam to evaluate a problem. You say that this should be covered because of the poor care you receive at another dentist.The Plan denied your request.The Plan says this is only covered once a year.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 Planoffers a dental benefit in excess of Medicare coverage, theexam at issue is covered only once per plan year.The record shows that you previously received this service during the 2020 plan year.Therefore, we decided that the Plan does not have to pay fora dental exam to evaluate a problem (D0140) provided on September 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for vision care and an ophthalmic ultrasounds provided on September 21, 2020. You asked the Plan to waive the copayments for vision care and an ophthalmic ultrasounds. You say that you disagree with how the charges were separated. 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 $40 copayment for vision care provided by a specialist. Your contract with the Plan also clearly says that you must pay a $10 copayment for diagnostic tests. You received vision care from a specialist on September 21, 2020. Therefore, you are responsible to pay the $40 copayment. You received two ophthalmic ultrasounds on September 21, 2020. Therefore, you are responsible to pay a $10 copayment per each test. The total amount you owe for ultrasounds is: $20. The total amount you owe is: $60. You have been asked to pay the total copayment amount of $60 for vision care and an ophthalmic ultrasound. Vision care falls within the vision care benefit category. Ophthalmic ultrasounds fall 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 copayments for vision care and an ophthalmic ultrasounds provided on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot inserts (L3000) provided on July 15, 2020.
You asked the Plan to pay for foot inserts. You say that these items should be covered at the in-network rate. The Plan denied your request. The Plan says these items is not a covered benefit for the billed diagnoses.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot inserts (L3000) provided on July 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic digital breast tomosynthesis coded 77062 provided on February 25, 2020.You asked the Plan to pay forthe diagnostic digital breast tomosynthesis. You say that you would like the plan to reconsider their denial.The Plan denied yourrequest. The Plan says the services rendered are not payable.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 77062 is diagnostic digital breast tomosynthesis; bilateral.We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay forthe diagnostic digital breast tomosynthesis coded 77062 provided on February 25, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on June 17, 2020.You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with this copayment for your father. The Plan denied your request. The Plan says the correct copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay an $80 copayment for emergency care. The enrollee has been asked to pay an $80 copayment for an emergency room visit. An emergency room visit falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on June 17, 2020. We note your complaint that if this was handled properly an emergency room visit would not have been necessary. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean advanced leg pump device for the enrollee.You asked the Plan to pre-approvethe device. You say that this is medically necessary.The Plan denied your request. The Plan says there is no documented four-week, multi-hour trial with an E0650 or E0651 documented in the medical records.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee has the unique characteristics that would indicate the segmental pump over a standard pump. Based on the medical records provided, there is no documentation of trial and failure of the standard pump 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 device have not been met.Therefore, we decided that the Plan does not have to pre-approvean advanced leg pump device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic mammography and ultrasound received on September 8, 2020.You asked the Plan to waive the copayment forthe diagnostic mammography and ultrasound. You say that you feel you should not be liable for the services.The Plan denied your request. The Plan says the claim was processed correctly per your plan benefits.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 diagnostic tests received in an outpatient hospital facility.You have been asked to pay a $100 copayment for the diagnostic mammography and ultrasound. The diagnostic mammography and ultrasound 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 copayment forthe diagnostic mammography and ultrasound received on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on August 25, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that you were advised that all dental benefits are covered for free. You also say that you were never given a benefit schedule.The Plan denied your request. The Plan says this service is not covered. The Plan also says that you received a problem focused limited oral evaluation on February 4, 2020, which was denied for the same reason.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 forthe problem focused limited oral evaluation provided on August 25, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis provided on August 26, 2020.You asked the Plan to pay forknee orthosis. You say that you are appealing with records clearly indicating medical necessity.The Plan denied your request. The Plan says the denial of payment for this item is correct, because the documentation submitted does not include proof of delivery for thebilled item.The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required for DMEPOS items to verify that the beneficiary received the billed item and thus to determine the amount due to the provider. We looked at the file and Medicare rules. The documentation submitted does not include proof of delivery for the billed item. Based on this information, we decided that Medicare rules for coverage of knee orthosis have not been met.Therefore, we decided that the Plan doesnot have to pay fora knee orthosis provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial hospital care (99222) provided on June 30, 2019.You asked the Plan to pay forthe initial hospital care. You say that you would like reconsideration because you rely on the facility for timely notification of patient's health insurance coverage.The Plan denied your request. The Plan says the claim was untimely and the submission did not meet exception criteria guidelines.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the initial hospital care was not filed until August 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe initial hospital care (99222) provided on June 30, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medicallynecessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 topre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with pneumonia and respiratory failure on December 12, 2020. He was intubated/ventilated upon presentation and shortly thereafter received a tracheotomy. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).

You asked the Plan to pre-approve the occlusal guard. The Plan denied your request. The Plan says this service is 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 pre-approve an occlusal guard (D9944).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient care provided from March 3, 2020, through March 6, 2020.You asked the Plan to waive the copayment forinpatient care. You say that you should not have to pay the copayment.The Plan denied your request. The Plan says the copayment was 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 $425 copayment per day; days 1 to 4 for inpatient hospital care. You have been asked to pay a $425 copayment per day; days 1 to 4 for inpatient care. This service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based onyour 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 forinpatient care provided from March 3, 2020, through March 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspiration in the setting of lumbar spinal surgery have not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental for use in spinal surgery. More research is needed to show safety efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage. 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 bone marrow aspiration for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from August 4, 2020, to August 11, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not cognizant enough to realize the amount of money you would have to pay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment per day for days 1-5 and $0 after day 5 each time you are admitted to an acute care hospital for inpatient hospital care. You have been asked to pay a $1,375 copayment for the inpatient hospital stay. ($275 x 5 days = $1,375). The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided from August 4, 2020, to August 11, 2020.
Your complaint about the unfair policy is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pacemaker removal rendered on March 24, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 33233 and 33235 are not covered.The Plan must follow Medicare rules. The rules say that the status indicator identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged. We looked at the file and Medicare rules. The provider billed codes 33233 and 33235. These codes have an OPPS status indicator of Q2, representing a packaged service. These codes were not billed with the required primary procedure for the packaged service. 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 forthe pacemaker removal rendered on March 24, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe magnetic resonance angiography of the head provided on July 25, 2020.You asked the Plan to pay forthe testing services. You say that the claim was denied as a duplicate in error.The Plan denied your request. The Plan says the records do not show that this test was separate from the magnetic resonance imaging of the brain.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that CPT code 70554 is a column II procedure to the billed code 70551. The tests are separately payable with a valid modifier. The claim provided does not include a modifier that would allow for separate payment.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe magnetic resonance angiographyof the headprovided on July 25, 2020.