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

We decided that the Plan does not have to pre-approve the van, the self-retracting "L" track and ramp provided on September 25, 2020

You asked the Plan to pre-approve these items. You say that you were informed the ramp would be covered. The Plan denied your request. The Plan says that the claim processed correctly.

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 these items 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 pre-approve the van, the self-retracting "L" track and ramp provided on September 25, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the manual therapy (97140) provided from June 5, 2020, through July 2, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have 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 $35 copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy services.
You have been asked to pay a $389.79 copayment for the Medicare-covered physical therapy services provided. This is the Plan's allowed amount for these services, which is less than the applicable copayments. 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 copayments for the manual therapy (97140) provided from June 5, 2020, through July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on March 25, 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 S1015 and S8301 are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on March 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71271) provided on March 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of this
code is 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.
We find that CPT code 71271 is not supported in the medical record. Specifically, the records show that only
one computed tomography (CT) scan was provided on the date of service in question. The Plan previously
processed and paid for one unit of CPT code 71271. Based on this information, we decided that Medicare rules
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the
services (71271) provided on March 11, 2021.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee will require therapy. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for non-healing wound at site of previous below the knee amputation and had an above the knee amputation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided on January 20, 2021.
You asked the Plan to pay for discharge day management. You say that the billed diagnosis codes are supported. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD- 10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. We looked at the file and Medicare rules. The services at issue were billed with a primary diagnosis of G92, toxic encephalopathy. This is a manifestation code, meaning the underlying condition should be coded first and this is not an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management (99239) provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic X-ray (D0330) and extraction of erupted tooth (D7210) provided February 24, 2021, to March 3, 2021.
You asked the Plan to pay for the panoramic X-ray and extraction of erupted tooth. You say that you would like this claim reprocessed for payment based on the provider's network status. The Plan denied your request. The Plan says the claim has processed correctly.
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. The Plan covers the panoramic X-ray once every year. In addition, the extraction of erupted tooth is covered with a coinsurance of 70%.
We looked at the file, and Medicare rules. In this case, the Plan has already covered the X-ray services and the benefit has been exhausted. In addition, the Plan has agreed to pay the 30% cost share as specified by the EOC for the oral surgery services of $42.90 ($143 Medicare allowed amount x 30% coinsurance). Therefore, you are responsible for the charged amount ($346) minus the Plan's agreed payment ($42.90). Based on this information, we decided that the Plan's rules for coverage of the panoramic X-ray and extraction of erupted tooth have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic X-ray (D0330) and extraction of erupted tooth (D7210) provided February 24, 2021, to March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from June 15, 2020, through June 17, 2020.
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
$345.00 copayment per day, for days 1 to 5 for inpatient hospital care. You have been asked to pay $690 ($345 copayment x 2 days) for the inpatient hospital care 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 inpatient hospital care provided from June 15, 2020, through June 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
December 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on
December 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 16, 2021 to February 21, 2021.

You asked the Plan to pay for home health services. You say that this should be paid as in-network. The Plan denied your request. The Plan says this was not billed with the correct type of bill.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was not submitted with the correct type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 16, 2021 to February 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET scan provided on October 17, 2020, by an OON
provider.
You asked the Plan to pay for the PET scan. You say that the service is medically necessary. The Plan denied
your request. The Plan says the claim originally denied for not meeting Medicare NCD/LCD criteria, but the
services are not authorized.
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. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the PET scan provided on October 17, 2020, by an OON
provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc for the left knee (CPT code J7327), for the enrollee.
You asked the Plan to pre-approve the medication. You say that you thought that since diagnosis was bilateral osteoarthritis (OA), that both knee injections would be approved. The Plan denied your request. The Plan says the enrollee was approved for right knee injection with Monovisc due to severe right knee pain secondary to OA of the right knee. The Plan states the documentation is for the right knee and no records were sent regarding the left knee. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medication have not been met. Review of the medical records provided only show right knee and leg pain. There were no medical records or x-ray's verifying left knee pain. Therefore, without this information we cannot make a determination on medical necessity. Therefore, we decided that the Plan does not have to pre-approve Monovisc for the left knee (CPT code J7327), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 27, 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 not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided on May 3, 2021.
You asked the Plan to pay for the services provided. You say that this service was pre-authorized. The Plan denied your request. The Plan says you have met the maximum benefit for services.
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 paid $250 for your routine eyewear. This allowed you to meet the maximum benefit for the services provided. You are responsible for any amount over $250. Therefore, we decided that the Plan does not have to further pay for the eyewear provided on May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that conservative treatments have failed to manage the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because there is no documentation that the enrollee has tried and failed a 4-week trial with a basic compression pump.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection (20610) arthroplasty, knee, condyle and plateau (27447) provided March 3, 2021.
You asked the Plan to pay for the arthroplasty services. You say that both the primary surgeon and the facility are in-network and CPT 247447 is payable to the assistant surgeon, you request the assistant surgeon's claim be processed at the in-network rate. The Plan denied your request. The Plan says the providers NPI indicate that they are a registered nurse. Additionally, the provider is non-participating. Certain Medicare non-participating providers are not recognized as payable by Medicare, this list includes registered nurses.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection (20610) arthroplasty, knee, condyle and plateau (27447) provided March 3, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve the Repatha Sureclick. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says Repatha Sureclick is on the self-administered drug list and is excluded from coverage under Part B. The Plan says that the enrollee does not have pharmacy benefits administered 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 pre-approve Repatha Sureclick. Benefits for the Repatha Sureclick 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 pathology services provided on February 3, 2021 by an outof-
network (OON) provider.
You asked the Plan to pay for pathology services. You say that these services were medically necessary. The
Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 pathology services provided on February 3, 2021
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator rental provided on
November 30, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable oxygen concentrator rental. You say that the service is medically
necessary, and you were told the enrollee's insurance was active. The Plan denied your request. The Plan says
no prior authorization was 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 portable oxygen concentrator rental provided
on November 30, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (K0195, K0003).

You asked the Plan to pre-approve the wheelchair. You say that The Plan denied your request. The Plan says you are independent with all activities of daily living.

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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is no indication that the mobility deficit would not be helped by a walker or cane. The records do not document the appropriateness of the home environment for the requested wheelchair. The records do not clarify that you cannot self-propel in a standard wheelchair in the home and can and do self-propel in a lightweight wheelchair.

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0195, K0003).