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

We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair and accessories.
You asked the Plan to pre-approve a Group 2 heavy duty power wheelchair and accessories. You say that you need a power wheelchair for access to your community and your favorite stores. The Plan denied your request. The Plan says the assessment shows you are able to complete your ADLs with a walker.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file shows that your condition can be improved by a walker and you cannot safely operate the PMD being requested inside your home due to clutter and doorway size. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study (95938) provided September 17, 2020.
You asked the Plan to pay for the evoked potential study. You say that the plan denied that the services were billed from an inappropriate place of service. This is incorrect. You billed this ancillary electroneuro diagnostic service from POS 15, mobile unit, which was correct and reimbursable. The Plan denied your request. The Plan says payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service.
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, we find that this service was provided to the enrollee while they were inpatient. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study (95938) provided September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that this is prescribed and medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intraoral - periapical first radiographic image (D0220), and the intraoral - periapical each additional radiographic image (D0230 x4) received January 7, 2021.

You asked the Plan to waive the coinsurance for the intraoral radiographic images. You say that the enrollee has a dental plan, and the requested services should be covered. The Plan denied your request. The Plan says the requested services were covered, and the correct cost share applied to the claim.

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 Class 2 Basic Services (Dental Services). 

The enrollee has been asked to pay $15.66 (20% coinsurance) for the intraoral radiographic images. The Plan allowed charges were $15.00 for procedure code D0230, x 4, and $18.32 for procedure D0220. 20% of the allowed amount equals $15.66. The intraoral radiographic images fall within the Class 2 Basic Services (Dental 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 coinsurance for the intraoral - periapical first radiographic image (D0220), and the intraoral - periapical each additional radiographic image (D0230 x4) received January 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on September 3, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home
health services under a plan of treatment.
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x
TOB. 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 home health services rendered on
September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on October 15, 2020.
You asked the Plan to pay for the knee orthosis (L1833LT) and suspension sleeve (L2397LT). You say that the orthoses are medically necessary The Plan denied your request. The Plan says reasonableness of the provided durable medical equipment has not been established.
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 knee orthosis (L1833LT) and suspension sleeve (L2397LT). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found 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 the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (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 the knee orthosis (L1833LT) and suspension sleeve (L2397LT) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on December 10, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on April 25, 2018 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for patient convenience items provided during an inpatient hospital stay on August 4, 2020.
You asked the Plan to pay for patient convenience items. You say that you would like the Plan to reprocess this claim and approve for payment. The Plan denied your request. The Plan says these items are not a covered service.
The Plan must follow Medicare rules. Medicare rules say that if a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or item is never covered, the plan does not have to hold the enrollee harmless We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of patient convenience items have not been met. Therefore, we decided that the Plan does not have to pay for patient convenience items provided during an inpatient hospital stay on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lift chair purchased October 15, 2020, from a provider not certified with Medicare.
You asked the Plan to pay for the lift chair. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the provider that supplied the durable medical equipment is not certified with Medicare and not able to receive payment.
The Plan must follow Medicare rules. Medicare rules say that for payment to be made to a durable medical equipment provider, the provider must be enrolled in the Medicare program. We looked at the file and Medicare rules. The file indicates that the provider is not certified with Medicare. Based on this information, we decided that Medicare rules for coverage of the lift chair have not been met. Therefore, we decided that the Plan does not have to pay for the lift chair purchased October 15, 2020, from a provider not certified with Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on October 14, 2020.
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that you believe this service should be covered. 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 pay for the adjunctive pre-diagnostic test (D0431) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and routine venipuncture provided by an out-of-network provider on December 14, 2020.
You asked the Plan to pay for the office visit and routine venipuncture. You say that it is the responsibility of the facility to obtain any and all authorizations. You say that the claim should be reviewed, and payment should be issued. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and routine venipuncture provided by an out-of-network provider on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 29, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you feel that this was your annual wellness exam. 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 $50 copayment for each specialist visit. The medical records show that you received specialist services on October 29, 2020. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on October 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection procedure provided on December 24, 2020.
You asked the Plan to waive the copayment for an injection procedure. You say that you were not informed that you would owe another copayment and disagree with the charges. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you received an injection procedure on December 24, 2020. An injection procedure is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for an injection procedure. An injection procedure falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an injection procedure provided on December 24, 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 you can safely receive the services you need in other settings.
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 were admitted for dizziness and dehydration.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on December 17, 2020.

You asked the Plan to pay for the services provided. You say that the provider performed the service in good faith. The Plan denied your request. The Plan says the billed code was not performed per the clinical note.

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 20550 is injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia"). 

The records show that trigger point injections were performed to the trapezius muscle. We find that CPT code 20550 is not supported in the medical record. Specifically, there is a more comprehensive code that describes the services provided. 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 for the injection services provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT) device (E0766).
You asked the Plan to pre-approve TTFT device. You say that the addition of this therapy within the NCCN Guidelines establishes this as a standard of care option for GBM patients. The Plan denied your request. The Plan says the records do not show that the enrollee meets the Medicare criteria for tumor treatment field therapy.
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 TTFT device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the criteria as there is no coverage for recurrent disease.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TTFT device have not been met. Therefore, we decided that the Plan does not
have to pre-approve tumor treatment field therapy (TTFT) device (E0766).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on July 6, 2020.
You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the medical records indicate that services were performed by a certified occupational therapist assistant (COTA) in the home health or hospice setting. The claim form indicates home visit evaluation billed on place of service 12. This means there is a more appropriate code that should be used to bill these services provided. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement CPAP and supplies.

You asked the Plan to pre-approve a replacement CPAP and supplies. You say that the enrollee needs a replacement CPAP and supplies. The Plan denied your request. The Plan says the compliance report reveals the enrollee did not utilize the machine for the amount of time indicated for adherence to therapy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The Compliance Summary Report shows that the enrollee was not compliant. Based on this information, we decided that Medicare rules for coverage of a replacement CPAP and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement CPAP and supplies.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (MPI) rendered on August 28, 2020.
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. 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 $220 copayment for covered diagnostic radiology services in the outpatient department of a network hospital or facility. You have been asked to pay a $220 copayment for these services. these services falls within the covered diagnostic radiology services in the outpatient department of a network hospital or facility 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 myocardial perfusion imaging (MPI) rendered on August 28, 2020.