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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 2, 2019 to October 24, 2019.
You asked the Plan to pay for the SNF services. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says the claims were billed incorrectly with the type of bill submitted and a corrected claim is needed for each claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The claims were billed incorrectly with the type of bill submitted and a corrected claim is needed for each claim. 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 pay for the skilled nursing facility (SNF) services provided September 2, 2019 to October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of attendance at the PACE center.
You asked the Plan to pre-approve PACE center attendance. You say that the PACE center days get you out of your apartment and you would hate to not be able to attend. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because your needs are being met at assisted living memory support, so attending days at the PACE center would be unnecessary for you to meet your needs.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 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 PACE center attendance. Our reviewer says that you do not meet the Medicare criteria for the requested PACE center attendance. Our physician reviewer found your current needs are being met through the assisted living memory support that you are receiving. Participation in the PACE center would be duplicative of this. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PACE center attendance have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of attendance at the PACE center.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
You asked the Plan to pre-approve the ventilator. The Plan denied your request. The Plan says ventilators used to provided CPAP or BiPAP therapy are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our physician reviewer found that the enrollee has COPD with hypercarbic respiratory failure, and may benefit from nocturnal respiratory support with BiPAP. However, Medicare does not pay for home ventilators used as BiPAP. The AVAPS-AE mode of ventilation can be provided with certain BiPAP devices. However, since the patient was unable to tolerate the mask interface in the past, it may be unlikely she will be able to tolerate it with BiPAP (or a ventilator). Therefore, a home ventilator is not 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 the ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiogram rendered to enrollee on August 21, 2019.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 93306 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 93306 is echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography.We find that CPT code 93306 is not supported in the medical record. Specifically, the records show that one unit of 93306 was previously approved and paid for the date of service at issue. There is no documentation to support additional units of the code. 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 echocardiogram rendered to enrollee on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series of x-rays (D0210) provided on December 3, 2019.
You asked the Plan to pay for the these services. You say that you are requesting a reconsideration of the Plan's denial for payment as you were told the x-ray services would be covered. The Plan denied your request. The Plan says these services are not a covered benefit under your dental policy. 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 services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete services of x-rays (D0210) provided on December 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) services provided to the enrollee from October 24, 2019 to October 31, 2019.
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 this is an invalid procedure code for this service.
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 HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy (HCPCS S9328) services provided to the enrollee from October 24, 2019 to October 31, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from May 5, 2019 to May 29, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the claim was billed with an invalid type of bill code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completedfor 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 claim that has been submitted does not include a valid type of bill.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from May 5, 2019 to May 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on October 31, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that the procedure was unnecessary and you only had it done because your doctor ordered it. 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 $350 copayment per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $350 copayment for the endoscopy.
You have been asked to pay a $196.15 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the endoscopy was performed to evaluate GERD.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the endoscopy provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377).
You asked the Plan to pre-approve an expandable controller (E2377). You say that the requested expandable controller is medically necessary. The Plan denied your request. The Plan says the requested expandable controller is not medically necessary.
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 an expandable controller (E2377). Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the enrollee was approved for a Group 3 power wheelchair and accessories with the exception of an expandable controller (E2377). Power recline, power leg elevators and power tilt were deemed not medically necessary. Per an 11/21/19 assessment the enrollee's right shoulder abduction strength 4/5, elbow flexion 5/5, elbow extension 5-/5, wrist flexion 4-/5, wrist extension 4-/5, hand intrinsics 4-/5, and grip 4-/5. On the left arm shoulder abduction strength 4/5, elbow flexion 5/5, elbow extension 5/5, wrist flexion 4/5, wrist extension 4-/5, hand intrinsics 4-/5, and grip 4-/5. Right shoulder abduction was 165 degrees and rest of bilateral upper extremities had full range motion. The enrollee was independent in eating. The requested expandable controller (E2377) is not medically necessary per LCA A52504. The documentation does not reveal that the enrollee requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. Power recline, power leg elevators and power tilt were deemed not medically necessary. The enrollee's upper extremity strength and feeding independently reveals the enrollee can sufficiently control any necessary power options with their separate 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 an expandable controller (E2377) have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe amalgam filling (D2150) for tooth # 11 provided on December 12, 2019.You asked the Plan to pay forthe dental service. The Plan denied your request. The Plan says the amalgam filling 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 amalgam filling is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe amalgam filling (D2150) for tooth # 11 provided on December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient surgical services (CPT 44130 and CPT 49020) provided to the enrollee on April 16, 2019.
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 denied codes are not supported by the submitted medical records.
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: CPT 44130: enteroenterostomic anastomosis of intestine, with or without cutaneous enterostomy (separate procedure) CPT 49020: open drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess 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 coded correctly. Our physician reviewer found the he medical records provided to not validate submitting an Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separate procedure) (CPT 44130) as a "separate" procedure, not related to other services being performed on the same patient at the same time by the same provider. Therefore, this code is not eligible for reimbursement consideration. The medical records submitted does not include documentation to validate that a Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open (CPT 49020) was performed on the enrollee on April 16, 2019. 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 inpatient surgical services (CPT 44130 and CPT 49020) provided to the enrollee on April 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care from December 21, 2018 through December 23, 2018 provided by an in-network provider.
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 EOC 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). Review of the file show that you received inpatient hospital care from December 21, 2018 through December 23, 2018 provided by an in-network provider. Your EOC clearly states, you pay 20% coinsurance for each Medicare-covered hospital stay. Your cost share should have been assessed as $1574.87; with the error cost share, it only assessed at $1485.65. The provider billed the plan $50,612.82 and the plan paid $6260.92. The Medicare allowable was $7874.34 and you were assessed 20% coinsurance of $1485.65. However; as stated above the cost share processed in error showing a lesser amount then the 20% cost share of $1574.87 and only assessed in your favor $1485.65. 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 inpatient hospital care from December 21, 2018 through December 23, 2018 provided by an in-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOneTouch Ultra Blue test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that the enrollee wants to continue to use the OneTouch brand.The Plan denied your request. The Plan says there is no medical reason to continue to use the non-preferred brand.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. There is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOneTouch Ultra Blue test strips.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an epidural steroid injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation of a trial and failure of conservative therapy, such as pain medicine or physical therapy.
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 injection. Our reviewer says that the requested injection is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has tried physical therapy, has both EMG/NCV and imaging that shows L5-S1 disc disease. The requested 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 injection have been met. Therefore, we decided that the Plan has to pre-approve an epidural steroid injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tinted lenses and anti-reflective coating rendered to you on October 21, 2019.
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.
The Plan must follow Medicare rules. Medicare rules say that tints and anti-reflective coating are covered when billed with the KX modifier to show medical necessity. We looked at the file and Medicare rules. The file shows that the services at issue were provided as convenience items and were not medically necessary. 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 tinted lenses and anti-reflective coating rendered to you on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (POV).
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a POV 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 you are ambulating household distances without assistance or use of an assistive device. You are able to ambulate further with use of a walker. You do not meet the criteria for coverage of the POV because you do not have a mobility limitation that that prevents you from performing mobility-related activities of daily living (MRADLs) in the home. The requested POV is not reasonable or medically necessary at this time.
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 power operated vehicle (POV).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test strips.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred brands and providers for durable medical equipment and supplies. We looked at the file and Medicare rules. Diabetic testing strips are covered from the preferred provider.
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 you decided not to be transported to the hospital after being asked by the ambulance staff if you were okay. You say that the ambulance staff should have identified whether you needed to go to the hospital or not. 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 on October 25, 2019. 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.