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

We decided that the Plan does not have to pre-approve knee-shin system add-ons (L5828, L5845, L5848, L5856) a knee extension assist (L5850), a knee or hip lock (L5925), a flex walk system (L5981), and protective covers (L5964).

You asked the Plan to pre-approve the prostheses. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says these items would exceed your needs.

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 prostheses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you are a K3 ambulator. Your recent approval for a power wheelchair and documentation that you do not have sufficient energy reserves or upper body strength do not support a K3 or above functional level. The L5964 additionally does not appear medically necessary as the documentation does not reveal that you need protection from unusually harsh environmental situations that indicate it is necessary to protect the limb beyond the level offered by an L5704-L5707. 

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 prostheses have not been met. Therefore, we decided that the Plan does not have to pre-approve knee-shin system add-ons (L5828, L5845, L5848, L5856) a knee extension assist (L5850), a knee or hip lock (L5925), a flex walk system (L5981), and protective covers (L5964).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab testing (80061, 83036, 85025, 84443) provided December 4, 2020.

You asked the Plan to waive the copayment for the lab testing. You say that this service should be covered under the diabetes screening benefit. The Plan denied your request. The Plan says the correct copayment was applied. This service was not a diabetes screening.

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 $15 copayment for laboratory services. 

You have been asked to pay a $15 copayment for the lab testing. The lab testing falls within the laboratory 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 lab testing (80061, 83036, 85025, 84443) provided December 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90791).

You asked the Plan to pay for the mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the mental health services was not filed until October 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90791).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).

You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 a PET CT scan from the skull base to mid-thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon the material provided there is no indication for PET/CT at this time. There is no mention of a recent physical exam or imaging finding to suggest tumor recurrence. There is no discussion concerning the rationale as to the reason for the request of the exam. Without such explanation of the medical necessity of the request the scan should not be approved at this time. If there has been clinical evidence of recurrence or conventional imaging study since 2018 those records should be made available to support the need for a follow-up PET/CT scan. 

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 PET CT scan from the skull base to mid-thigh have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on November 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 99053 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code 99053 (service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and has no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered on November 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.

You asked the Plan to pre-approve the continued physical therapy services. You say that you would like reconsideration because the member was on track to meet their goals but then experienced a functional decline. The Plan denied your request. The Plan says there is no indication for continued skilled services.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 continued physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. 

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 continued physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller (E2377, E2313) and shoe holders (K0108).

You asked the Plan to pre-approve the expandable controller and shoe holders. You say that these items are not medically necessary. The Plan denied your request. The Plan says coverage for these items cannot be made.

The Plan follows Medicare rules. Medicare rules say that equipment to be covered, it must primarily serve a medical purpose. The rules also say that an expandable controller must meet the criteria listed in the Medicare rules section. 

Expandable Controller 

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 expandable controller. Our reviewer says that the requested expandable controller is not medically necessary and reasonable. Our physician reviewer found the patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's strength and function in the upper extremities with the ability to perform toileting independently indicates that the patient can control any power options through their own individual switches.
Shoe Holders

The shoe holder 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. 

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 expandable controller and shoe holders have not been met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377, E2313) and shoe holders (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood glucose monitor and supplies (E0607, A4253, A4259, A4256, A4258) provided on January 24, 2020, through April 23, 2020.
You asked the Plan to pay for the blood glucose monitor and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include a proof of delivery or physician order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Without this information, the billed supply codes cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the blood glucose monitor and supplies (E0607, A4253, A4259, A4256, A4258) provided on January 24, 2020, through April 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

Explanation of decision
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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for eyewear which includes frames (V2020), trifocal lenses (V2300, V2303) and anti-reflective coating (V2750), provided on January 4, 2021.
You asked the Plan to pay for the eyewear. You say that you know that you have a $300 maximum annual allowance for eyewear but are confused by the denial. You want to verify that the Plan has paid their agreed-upon $300 portion of these glasses. The Plan denied your request. The Plan says they have paid the annual maximum of $300 for these glasses, but the remainder of the cost is your responsibility as the full cost of $514 exceeds what the Plan allows. The Plan is asking you to pay the $214 in excess of what the Plan allows.
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. The Plan covers these services up to a maximum allowance of $300 per year. We looked at the file and the Plan's rules. The Plan provided documentation that they have paid the maximum allowance of $300 for these services, and you were only expected to pay the $214 that exceeded the $300 allowance. Therefore, we decided that the Plan does not have to pay anything else for eyewear which includes frames (V2020), trifocal lenses (V2300, V2303) and anti-reflective coating (V2750), provided on January 4, 2021.
Your complaint about confusing correspondence from the Plan which indicates they denied services which were, in fact, approved and paid for according to the terms of your contract is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints. Please note however, that the Plan has paid for their portion in this case and the denial they sent was only regarding the full $512 cost of the eyewear.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a bone conduction implant.

You asked the Plan to pre-approve implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy (69714). You say that the enrollee has tried hearing aids multiple times without benefit. The Plan denied your request. The Plan says that there is no documentation of cortical bone thickness of 3mm or more and no signs of a lack of improvement with air conduction hearing aid.

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 implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy (69714). Our reviewer says that criteria is met. Our physician reviewer found a bone anchored hearing device is approved by the FDA for either single sided deafness (which this patient does not have), or for mixed or conductive hearing loss in the ipsilateral ear. A bone anchored hearing implant can be indicated for a patient with a draining ear, which this patient has. It is not critical for the cortical bone to be 3mm or more. This measurement is just helpful for the surgeon to know when operating. The patient has a known mixed hearing loss in the ear that is to be implanted. The patient has tried air conduction hearing aids in the past without benefit. In this case the patient meets the criteria for a bone anchored hearing implant. 

We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy (69714) have been met. Therefore, we decided that the Plan has to pre-approve a bone conduction implant.

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge day management provided on
July 1, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the provider rendered
medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the
enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it
is the provider's responsibility to verify the member's coverage before rendering services and to know proper
billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the observation care discharge day management provided on
July 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 19, 2020.

You asked the Plan to pay for the laboratory services. You say that the services were provided to the enrollee prior to their admission to hospice. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 the laboratory services provided on June 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 19, 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 codes 71045, 87804, and U0004 were not billed correctly.
The Plan must follow Medicare rules. The rules say that outpatient hospital bills are subject to OPPS payment. We looked at the file and Medicare rules. Procedure codes 71045, 87804, and U0004 were billed with modifier -CS. This modifier is for COVID-19 testing only and is not payable for these codes per OPPS billing. 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 October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 13, 2020, by an out of network dentist.
You asked the Plan to pay for the dental services. You say that you were never notified that your dental coverage was provided by a new dental plan. You say that your plan's website does not state which Dental Plan provide coverage either. You also say that you should not be responsible for the charges. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services that are performed out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 13, 2020, by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on August 20, 2020.
You asked the Plan to pay for the dental service. You say that you had extensive work done by this provider. You also say that this service should be covered. The Plan denied your request. The Plan says consultation is not listed as a covered service. The Plan also says that any services not listed are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment (PPE)(D1999) provided on September 22, 2020.
You asked the Plan to pay for the PPE. You say that your booklet says preventive dental service provided up to $1,500 every year are covered. The Plan denied your request. The Plan says personal protective equipment is not a covered service.
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, personal protective equipment (PPE) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the personal protective equipment (PPE)(D1999) provided on September 22, 2020.