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

We decided that the Plan does not have to pre-approve power mobility device features defined by codes E2300, K0108, E2377, E2313, E2311.
You asked the Plan to pre-approve power mobility device features. You say that the power wheelchair is necessary. The Plan denied your request. The Plan says they agree that the power wheelchair is necessary and will overturn the request for a group 2 power wheelchair, but found that the denial for these additional features remain denied.
The Plan follows Medicare rules. Medicare rules say that they will cover services that are reasonable and medically necessary. A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. The expanded controller components (E2377, E2313, E2311) are requested to control power options through the joystick. There is not a medical need to control power options through the joystick. Because enrollee is able to the control power tilt with its own switch, there is no need to control the power option through the joystick. Since power tilt and recline and leg elevation feature includes a switch control and member is able to operate the switch controller, the upgraded electronic (expandable controller) is not needed. The member does not need to operate these power options through the joystick. The denial is correct. Durable medical equipment is covered it is appropriate for use in the member's home. The transit kit is used to strap the wheelchair to a vehicle to travel outside the home. The denial is remains. This means that Medicare rules for coverage of a PMD features have not been met. Therefore, we decided that the Plan does not have to pre-approve power mobility device features defined by codes E2300, K0108 ,E2377, E2313, E2311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid provided by an out-of-network provider on March 11, 2021.
You asked the Plan to pay for the hearing aid. You say that your provider is excellent, gave good service and a good piece of equipment. You say that you found no reason to go elsewhere and you should receive what a patient going to an in-network audiologist would receive. The Plan denied your request. The Plan says hearing aids ordered through providers other than network providers are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from a network provider. We looked at the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid provided by an out-of-network provider on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the enrollee requires the device because of their medical condition. The Plan denied your request. The Plan says the documentation does not support medical necessity.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the service is not medically necessary. Our physician reviewer found enrollee's condition does not require position of the body in ways not feasible in an ordinary bed. The enrollee does not require frequent changes in body position. There is no need for immediate changes in body position. The enrollee's condition does not require special attachments that cannot be fixed and used on an ordinary bed. The requested semi-electric hospital bed 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chiropractic manipulative treatment (98941) provided on April 26, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $20 copayment for Medicare-covered chiropractic services at an in-network specialist's office.
You have been asked to pay a $20 copayment for the Medicare-covered chiropractic services provided. 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 chiropractic manipulative treatment (98941) provided on April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81321, 81318, 81201, 81301) provided on March 25, 2021.

You asked the Plan to pay for Guardant360 testing. You say that this is a covered service. The Plan denied your request. The Plan says this was not billed correctly.

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 rules also say that code 81479 is used to report Guardant360 testing. 

We find that CPT codes 81321, 81318, 81201, 81301 are not supported in the medical record. Specifically, these codes were used to report Guardant360 testing, which should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81321, 81318, 81201, 81301) provided on March 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 6, 2021 through January 27, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you are being treated for cancer and did not know the provider was out-of-network. You say that you shouldn't be responsible. The Plan denied your request. The Plan says self-administered drugs are not covered by the Plan.
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 pay for the self-administered drugs provided from January 6, 2021 through January 27, 2021.
Benefits for the self-administered drugs 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: 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 if the enrollee is not admitted they are physically unable to move and do anything on their own. The Plan denied your request. The Plan says an IRF stay is not medically necessary.
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. Our physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of
rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as a skilled nursing facility. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission technology (PET) scan provided on April 15, 2021.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the services were not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used.
We looked at the file and Medicare rules. In this case, the PET scan was not billed with an appropriate
diagnosis code as outlined by Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the
positron emission technology (PET) scan provided on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88312, 88305) provided on March 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that this should not be considered out-of-network because the enrollee did not come to the laboratory. The Plan denied your request. The Plan says this was not authorized or referred by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that 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 laboratory services (88312, 88305) provided on March 31, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for wound care. We decided that the Plan does not have to waive the copayment for wound care.
You asked the Plan to reduce the copayment for wound care. You say that The Plan says that
We decided that the Plan has to reduce the copayment for wound care.
You cannot be charged more than a $350 copayment for an outpatient surgery. Therefore, we decided that the Plan has to reduce the copayment for wound care.
We also decided that the Plan does not have to waive the copayment for wound care.
There is a $350 copayment for wound care. Since wound care was provided at an outpatient hospital facility, a $350 copayment must be applied. Therefore, we decided that the Plan does not have to reduce the copayment for .
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography coded 95867 and 95870 and the continuous intraoperative neurophysiology monitoring coded G0453 provided on December 15, 2020.
You asked the Plan to pay for the needle electromyography and the continuous intraoperative neurophysiology monitoring. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were not billed with covered diagnosis codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT codes 95867, G0453, and 95870 are not supported in the medical record. Specifically, these codes were billed with diagnosis code K11.8. This diagnosis code is not listed as a diagnosis code that supports medical necessity of these codes. In addition, code G0453 is only payable when billed with a covered primary procedure. Based on this information, we decided that Medicare rules for coverage of the needle electromyography and the continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography coded 95867 and 95870 and the continuous intraoperative neurophysiology monitoring coded G0453 provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and debridement rendered on March 15, 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 11721, 99213, and 11056 are not separately payable.
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services and post-operative visits are included in the global surgical package. We looked at the file and Medicare rules. The file shows that procedure codes 11721 (debridement of nails), 99213 (office visit), and 11056 (paring or cutting of benign hyperkeratotic lesion) were billed within the 90 day global surgical period and related to the initial surgical procedure, code 28192 (removal of foreign body on foot) billed on December 23, 2020. Payment for these services is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit and debridement rendered on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 23, 2021.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumonia vaccine provided on January 26, 2021.
You asked the Plan to pay for this vaccine. You say that you were not aware you would need to pay for this vaccine. The Plan denied your request. The Plan says your last pneumonia vaccine was May 19, 2018. You were not eligible for this vaccine as this benefit is only covered twice in a lifetime.
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 the pneumonia vaccine is covered twice in a lifetime under Medicare. This benefit was not available at the time of service. You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation. Therefore, we decided that the Plan does not have to pay for the pneumonia vaccine provided on January 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 7, 2021, to February 5, 2021.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled service on the dates of service in this case.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 7, 2021, to February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Part B drugs, anesthesia, laboratory service (88305), ringers lactate infusion (J7120), and the propofol injection (J2704) provided on February 3, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $325 copayment for Medicare-covered surgery or other services provided at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $316.05 copayment for the Medicare-covered services provided at an outpatient hospital. This is the Plan's allowed amount for these services which is less than the applicable copayment. 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 Part B drugs, anesthesia, laboratory service (88305), ringers lactate infusion (J7120), and the propofol injection (J2704) provided on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on March 11, 2021 by an out-of-
network (OON) provider.

You asked the Plan to pay for wound care services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's
primary care physician. The Plan says that the referring provider is out-of-network.

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 wound care services provided on March 11, 2021
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation trips with additional mileage.
You asked the Plan to provide additional mileage. You say that you need this transportation to see this provider, and you were told you needed prior authorization. The Plan denied your request. The Plan says only trips of 50 miles or less are covered by this benefit. The requested location is more than 50 miles away.
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 up to 24 routine transportation trips per year. Trips must be to or from Plan approved locations and must not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. The requested location is more than 50 miles away. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide routine transportation trips with additional mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
You asked the Plan to pre-approve a portable ventilator. You say that a portable ventilator is medically necessary. The Plan denied your request. The Plan says that there is no evidence that the requested mechanical ventilator is indicated.
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 a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary for the enrollee in this case. The member has severe chronic obstructive lung disease and has been prescribed Bilevel positive airway pressure (BiPAP) as a nocturnal respiratory assist device. The patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.