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

We decided that the Plan does not have to pay for the durable medical equipment rendered on December 10, 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 procedure code E1399 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 E1399 is durable medical equipment, miscellaneous. We find that CPT code E1399 is not supported in the medical record. Specifically, there is no documentation to support that miscellaneous durable medical equipment was rendered.
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 durable medical equipment rendered on
December 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on May 8, 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 services are not covered.
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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and there is a more appropriate code for these services. The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 95955 and 95957. Code 95957 is a column II code with a modifier indicator of 1 when billed with column I code 95955. Code 95957 was not billed with an appropriate modifier to allow for separate payment. 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 testing services rendered on May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional charges above $600 for the purchase of contact lenses.You asked the Plan to pre-approveadditional charges above $600 for the purchase of contact lenses. You say that you cannot afford to pay for the contact lenses.The Plan denied your request. The Plan says additional charges above $600 are not a covered vision benefit with the Plan.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. The file shows that the Plan's routine eyewear benefit has a maximum of $600 and the enrollee is responsible for all costs above the $600 maximum. Therefore, we decided that the Plan does not have to pre-approveadditional charges above $600 for the purchase of contact lenses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefour removals of impacted teeth (D7220 x4).You asked the Plan to pre-approvethe removals of impacted teeth. You say that you need these teeth removed because you are very sick with them remaining in your mouth.The Plan denied your request. The Plan says these services are not covered under your benefit package.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvefour removals of impacted teeth (D7220 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea stair glide.You asked the Plan to pre-approvea stair glide. The Plandenied your request. The Plan says this item is not a covered benefit.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 pre-approvea stair glide.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from August 1, 2020, to August 29, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you were given the wrong information and told that you would not owe anything for the stay. 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 $0 copayment for days 1-20, and a $165 copayment for days 21-100 for SNF care. You had a SNF stay from July 28, 2020, to August 1, 2020. You are not being charged a copayment for days 1-
20 (July 28, 2020, to August 16, 2020). You are responsible to pay a $165 copayment for days 21-33 (August 17, 2020, to August 28, 2020). $165 (copayment) x 12 (SNF days) = $1,980. You have been asked to pay the total copayment amount of $1,980 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from August 1, 2020, to August 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to scooter (K0739) and replacement battery charger (E2366).
You asked the Plan to pre-approve repairs to scooter and replacement battery charger. You say that it is medically necessary for the enrollee to receive these items. The Plan denied your request. The Plan says the enrollee was recently approved for a manual wheelchair which serves the same purpose as the requested items.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and 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 repairs to a scooter and replacement battery charger. Our reviewer says that these items are not medically necessary. Our physician reviewer found the enrollee was given approval for a standard wheelchair. A second mobility device is not medically reasonable and necessary at this time. We looked at this physician's review, the file, and Medicare rules. The file shows that the enrollee has a manual wheelchair. A manual wheelchair serves the same purpose as repairs to scooter and replacement battery charger. Therefore, we decided that the Plan does not have to pre-approve repairs to scooter (K0739) and replacement battery charger (E2366).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 4, 2021.
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 codes 88184 and 88185 are duplicate claims and code 88187 is not separately payable.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that codes 88184 and 88185 were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules state that providers may bill services with the -XE modifier if the service billed with the modifier indicates a distinct procedural service.
The medical records provided do not show that procedure code 88187 (flow cytometry, interpretation; 2 to 8 markers) billed with the -XE modifier is a distinct procedural service.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional five routine transportation trips for the enrollee.
You asked the Plan to pre-approve the additional trips . You say that this is medically necessary. The Plan denied your request. The Plan says this request exceeds the maximum count for transportation allowed per period.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional five routine transportation trips for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears more stable and improving but is still requiring additional short-term acute care services that can safely be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered soon. Intravenous (IV) antibiotics can be arranged to be given at a lower level of 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to skilled nursing facility does not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the SNF. Upon evaluation, you were at an independent to supervision/ touch assist level with functional mobility including gait to 150 feet. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty walker and seat attachment to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a heavy duty walker and seat attachment. You say that these items are medically necessary.The Plan denied your request. The Plan says that there are in-network provider(s) within a reasonable distance from your location that can provide this service or item.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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.Therefore, we decided that the Plan does not have to pre-approve a heavy duty walker and seat attachment to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic (Current Procedural Terminology (CPT) code 96402) and the office visit (CPT code 99213) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan denied your request. The Plan says there are providers in-network that can perform the services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. Therefore, we decided that the Plan does not have to pre-approve chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic (Current Procedural Terminology (CPT) code 96402) and the office visit (CPT code 99213) to be performed by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oximeter (E0445) for the enrollee.
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that oximeters (E0445) will be denied as non-covered. The requested item is statutorily not covered by Medicare or the plan. Based on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-approve an oximeter (E0445) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are necessary. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. This request exceeds your
benefit. The 25th trip and beyond is not a covered benefit. Your 2021 EOC states that enrollees must pay a $0 co-payment per trip for twenty-four (24) one-way trips every year to plan approved locations. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveaccelerator and brake hand controls for a vehicle.You asked the Plan to pre-approvehand controls for a vehicle. You say that you cannot depend on other people to transport you.The Plan denied your request. The Plan says rules for durable medical equipment have not been met.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approveaccelerator and brake hand controls for a vehicle
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre device (K0554) with supplies (K0553).
You asked the Plan to pre-approve a Freestyle Libre device with supplies. You say that your primary care physician says that you need the requested items. The Plan denied your request. The Plan says rules for a therapeutic CGM have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre device with supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre device (K0554) with supplies (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the level of care provided in the LTACH setting is more than medically needed.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee x-ray rendered on February 5, 2021.

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 were billed incorrectly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.

We looked at the file and Medicare rules. The file shows that procedure code 73560 (knee x-ray) was billed with an inappropriate diagnosis code. The provider must resubmit a corrected claim to the Plan.Therefore, we decided that the Plan does not have to pay for the knee x-ray rendered on February 5, 2021.