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

We decided that the Plan does not have to waive the coinsurance for a walking boot (L4361).

You asked the Plan to waive the coinsurance for a walking boot. You say that the supplier is charging nearly three times the prevailing retail price. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for durable medical equipment.

You have been asked to pay $44.09, or 20% of the Medicare-allowed amount of $220.46, for a walking boot. A walking boot falls within the "Durable medical equipment (DME) and related 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 coinsurance for a walking boot (L4361).

Your complaint about the Plan permitting the DME supplier to overcharge its enrollees 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 pre-approve an interspinous spacer device.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the insertion of a lumbar interspinous spacer would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says there remains a lack of studies which compare interspinous spacers to standard treatments such as decompression surgery.

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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the infusion services.

You asked the Plan to waive the copayment for therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug (96374). You say that you were not told you would have a copayment for this service. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Outpatient Hospital Services.

You have been asked to pay a $150 copayment for therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug (96374). Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug (96374) falls within the Outpatient Hospital 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 the infusion services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using the requested items with benefit. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that a knee orthosis with adjustable knee joints is covered when the criteria listed in the "Medicare rules" section of this letter 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 pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (suspension 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 a knee orthosis have not been met. Furthermore, a suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.

You asked the Plan to pay for foot orthotics. You say that you have worn inserts for years because of a congenital health condition. The Plan denied your request. The Plan says this item is not a covered benefit.

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 orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran additional unit of observation care discharge day management services (CPT 99217) provided to the enrollee on February 5, 2020.You asked the Plan to pay forthe additional unit. You say that this should be paid for.The Plandenied your request. The Plan says the submitted documentation supports one unit of CPT 99217, which was previously approved and paid.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers mustreport services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99217 is "Observation care discharge day management."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 additional unit. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation provided validates this service was previously billed and paid. The documentation provided confirms that the Provider was reimbursed $72.23 for CPT code 99217 on a Provider Remittance Advice with a check date of 4/16/2020. Also, CPT 99217 has an MUE of 1per date of service, therefore, this code is not eligible for reimbursement more than one time per provider/practice per date of service.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional unit have not been met.Therefore, we decided that the Plan does not have to pay foran additional unit of observation care discharge day management services (CPT 99217) provided to the enrollee on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office services to be provided at the in-network benefit.
You asked the Plan to pre-approve office services. You say that nothing has changed in the past year and you want to keep this provider. The Plan denied your request. The Plan says the denial of coverage at the in-network benefit level is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees may choose to receive care from out-of-network providers, however the cost-share for out-of-network services may be higher. 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 at the in-network benefit level. You may choose to receive service from the Plan's out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-approve office services to be provided at the in-network benefit level.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that a review of the current medical literature indicates that this service is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is being treated for chronic low back pain. Progress note cites complaints of chronic pain to the neck, low back, and chronic pain due to fibromyalgia. Her lower back pain is improving somewhat with the conservative treatments and epidural injections but continues to be present all the time with aching and throbbing sensations that will radiate into her left lower extremity down to her ankle, and down her left lower extremity extending to lateral knee. Pain is rated at 5-6 out of 10. Pain is alleviated by rest and medications. Pain is made worse by walking and standing. The pain affects her ability to perform household chores and prepare meals. Exam of the lumbar spine reveals tenderness to palpation of the bilateral paraspinals. Pain with forward flexion is noted. She is slow to rise from seated position. There is mild pain with facet loading. Straight leg raise is negative. Strength is intact bilateral upper and lower extremities. MRI corroborates severe chronic degeneration of the L5-S1 disc with modic type 2 changes on both sides of the L5-S1 disc, minimal degenerative signal loss in the L4-5 disc. Provided documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of conservative treatment modalities has been well documented, including medications, physical therapy, and injections. Therefore, the requested Intracept procedure is medically reasonable and 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve the Intracept procedure for the enrollee.

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 procedure have been met. Therefore, we decided that the Plan has to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture adjustment (D5751).

You asked the Plan to pay for the dental service. You say that your denture will not stay in place while you eat. You say that this is affecting your eating pattern. You say that your dentist adjusted them to work properly. You also say that this is important to your health. The Plan denied your request. The Plan says denture adjustment is not listed as a covered service.

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 denture adjustment (D5751).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says there is no coverage for telehealth psychotherapy services from a non-participating provider with no prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, E2311, E2313).

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to control the three approved power options through the joystick.

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 additional accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that you do not require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.), non-proportional input devices (e.g., sip and puff, head array, etc.). You do not need to operate 3 or more powered seating actuators through the drive control. You do not need a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. You have sufficient upper extremity strength and function to operate any power options through their own individual switches.

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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, E2311, E2313).
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 you need extensive monitoring. The Plan denied your request. The Plan says your needs could be me 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 above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the documentation does not support that the complexity of your nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require additional therapy, the documentation does not support the need for an intensive rehabilitation therapy program.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for exercise equipment (A9300).

You asked the Plan to pay for exercise equipment. You say that this purchase was due to the COVID-19 pandemic and there should be no date limit for the reimbursement. The Plan denied your request. The Plan says rules for payment have not been met.

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 permits the use of gym benefits toward the purchase of exercise equipment.

The Plan's rules for coverage of gym benefits have not been met because the requested exercise equipment was purchased prior to the coverage window. Therefore, we decided that the Plan does not have to pay for exercise equipment (A9300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3908).

You asked the Plan to pay for a wrist-hand orthosis. You say that the requested item was necessary because your wrist was broken. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order or proof of delivery. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3908).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960).

You asked the Plan to pay for a shoulder-elbow-wrist-hand orthosis. You say that the requested item is necessary. The Plan denied your request. The Plan says rules for payment have not been met.

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 pay for a shoulder-elbow-wrist-hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that, based on the medical records provided, there is no documentation that the shoulder-elbow-wrist-hand orthosis at issue in this case is medically reasonable and necessary. The provided medical records are inadequate to document necessity of the orthosis as there is no documentation of a face-to-face physical examination or a telehealth examination of the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a shoulder-elbow-wrist-hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that both your son and the police called for this service. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical nutrition therapy.

You asked the Plan to pre-approve medical nutrition therapy services. You say that you would like reconsideration because you would like to get nutrition therapy or dietary counseling to prevent becoming diabetic. The Plan denied your request. The Plan says overage criteria supplied by Medicare do not support coverage in this case.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.

Records do not show that you suffer from renal disease or diabetes. Specifically, the record shows that you have pre-diabetes which does not meet the definition of diabetes. Therefore, we decided that the Plan does not have to pre-approve the medical nutrition therapy.