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

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance
(E0673) provided on October 13, 2020.
You asked the Plan to pay for the segmental gradient pressure pneumatic appliance. You say that you would
like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for
this service is the responsibility of the facility or hospital that provided the surgery.
The Plan must follow Medicare rules. Medicare rules say that if the base PCD is not covered, related
accessories are not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the segmental gradient pressure pneumatic appliance have not been met. Specifically, there is no
evidence that a covered base PCD was provided so the requested accessory is not eligible for reimbursement.
Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic
appliance (E0673) provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro orthosis device.
You asked the Plan to pre-approve the MyoPro orthosis device. You say that you would like reconsideration because the Myopro orthosis will effectively replace the member's elbow and help restore the member's right arm strength and range of motion. The Plan denied your request. The Plan says the record only includes a signed prescription order and no medical records over a period of time or medical records showing that the prescribing medical provider recommended this device.
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 MyoPro orthosis device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this member, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 MyoPro orthosis device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro orthosis device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 23, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were part of an 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 $10 copayment for laboratory tests. You received laboratory services on November 23, 2020. Laboratory services are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for laboratory services. Laboratory services 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 copayment for laboratory services provided on November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from February 27, 2020 to March 7, 2020.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says in order to determine if the member's foreign services are medically necessary, the payment request must include an itemized bill which lists the services that were rendered.
The Plan contract says that an itemized bill must be submitted to the Plan.
We looked at the file and the Plan's rules. The file does not contain an itemized bill that lists the services that were provided. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from February 27, 2020 to March 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on September 1,
2020.
You asked the Plan to pay for therapeutic activities. You say that this should be covered. The Plan denied your
request. The Plan says the records do not support this code.
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, this is a time-based code and
the records do not document the amount of time spent on this service. Based on this information, we decided
that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the
Plan does not have to pay for therapeutic activities (97530) provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on January 19, 2021.
You asked the Plan to reimburse you an additional amount for the eyeglasses. The Plan denied your request. The Plan says that the Plan reimbursed you the correct eyewear allowance of $150.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a $150 allowance every 24 months. We looked at the file and the Plan's rules. The file shows that the Plan sent a check in the correct amount of $150 to you on February 17, 2021 for the purchase of the eyewear. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism placed in a vehicle (E0627) provided
September 3, 2020.
You asked the Plan to pay for the seat lift mechanism placed in a vehicle. You say that this is necessary for you
to use your vehicle. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
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. Therefore, we decided that the Plan does not
have to pay for the seat lift mechanism placed in a vehicle (E0627) provided September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
November 5, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 services 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 subsequent nursing facility care provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on October 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that attached is an appeal with medical notes for further review of claim. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99215) provided on October 27, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide.
You asked the Plan to pay for a stair glide. You say that it has gotten more difficult to go up the stairs. The Plan denied your request. The Plan says this is not a covered service.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for special services, after hours services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053).
You asked the Plan to pay for the after-hours services. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says payment for the services provided is included in the approved emergency department services
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 have confirmed that 99053 has a bundled relationship with the approved emergency department services and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for special services, after hours services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053).
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 COVID-19 pneumonia. 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 waive the copayment for the specialist office visit provided on February 4, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have a copayment for each infusion service. The Plan denied your request. The Plan says you were charged this coinsurance 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 $40 copayment for Physician Services. You have been asked to pay a $40 copayment for the specialist office visit. the specialist office visit falls within the Physician 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 specialist office visit provided on February 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 29, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical laparoscopy, repair of paraesophageal hernia, includes fundoplasty, when performed (43282) provided December 18, 2020 to December 19, 2020.
You asked the Plan to waive the copayment for the surgical laparoscopy. You say that you are appealing because you did not know that is the case for the specialty room. The Plan denied your request. The Plan says the claim was processed correctly per the Evidence of Coverage.
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 each outpatient hospital facility visit, including physician or surgical charges. You have been asked to pay $1,757.73 for the surgical laparoscopy. The surgical laparoscopy 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 the surgical laparoscopy, repair of paraesophageal hernia, includes fundoplasty, when performed (43282) provided December 18, 2020 to December 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomeprazole magnesium for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esomeprazole magnesium for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laboratory services provided by an out-of-network provider on April 30, 2020.
You asked the Plan to pay for the office visit and laboratory services. You say that you are contracted for Medicare Plans and are losing out on reimbursement. You say that the claim should be processed at the contracted rate. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 laboratory services provided by an out-of-network provider on April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on January 4, 2021.
You asked the Plan to pay for the resin-based composite. You say that the provider advised that your insurance would cover one filling per year. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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 resin-based composite provided on January 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services (99285) provided on
September 1, 2020.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration
because this service was billed appropriately. The Plan denied your request. The Plan says the documentation
does not supper the evaluation and management level as reported on the 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.
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation
and management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high
severity and pose an immediate significant threat to life or physiologic function.
We asked our coder 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 emergency department services. Our reviewer says that
CPT code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the
emergency room visit supports a comprehensive history and exam, with medical decision making of moderate
complexity for laboratory, ECG, chest x-ray, and prescription medication. Therefore, the services provided
support CPT 99284.
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 emergency department services have not been met. Therefore, we decided
that the Plan does not have to pay for the emergency department services (99285) provided on September 1,
2020.