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

We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee has undergone conservative treatments utilizing compression, exercise and elevation; however, the enrollee demonstrated no significant improvement of their overall swelling despite use of conservative therapies. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME have not been met. There is no examination of the enrollee's belly/trunk that shows the enrollee shows lymphedema there. Also, the therapy plan only mentions the goals of decreasing the leg swelling. Medicare rules state, "A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be denied as not reasonable and necessary." There is more than one type of compression pump system that is used for lymphedema (swelling in the legs like you have). Medicare only considers the segmental type of compression pump when the swelling is also at your chest and belly (abdomen) areas. The records do not show you have the problem at the chest and abdomen (belly). Therefore, we decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on February 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 99291 is " Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes". We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not support that 30-74 minutes of critical care services were provided on the date of service in question.
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 critical care services (99291) provided on February 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on February 12, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lumbar spine for the enrollee.

You asked the Plan to pre-approve the MRI. You say that The Plan denied your request. The Plan says that there is no clinical indication for immediate advanced imaging.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found while the had a prior abnormal MRI of the lumbar spine on February 7, 2019, his recent exacerbation was accompanied by a diminished right patellar deep tendon reflex. No new weakness was described, but the enrollee has a history of frequent falls and cannot get out of a chair without assistance. He has a positive straight leg raise on the right. While the diminished DTR on the right may be chronic, the fact that the enrollee falls often and can't get out of a chair without assistance provide indications for MRI of the lumbar spine without the six week trial of physical therapy. 

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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the lumbar spine for the enrollee.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home infusions provided from January 1, 2021, through April 2, 2021.
You asked the Plan to waive the coinsurance for the home infusions. You say that you are on a fixed income and this is difficult to pay. You say that you are requesting the Plan increase the percent they are paying. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for home infusion therapy. Home infusion therapy involves the intravenous or subcutaneous admission of drugs or biologicals to an individual at home. The components needed to perform home infusion include the drug (for example, antivirals, immune globulin), equipment (for example, a pump), and supplies (for example, tubing and catheters). You have been asked to pay $3,009, which is 20% of the allowed amount for the home infusions. The allowed amount is $15,045 (20% x $15,045 = $3,009). The home infusions fall within the "Home infusion therapy" 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 coinsurance for the home infusions provided from January 1, 2021, through April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered on February 9, 2021.

You asked the Plan to pay for these services. You say that you were not aware the provider was not in-network. The Plan denied your request. The Plan says the services 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. The Plan covers supplemental dental benefits from a network provider only.

We looked at this the file and Medicare rules. The file shows that you received services from a provider who is not a network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services rendered on February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Detailed
documentation is not evident regarding specific indication provided to support the request for bone marrow
aspirate for the approved surgery. There is limited published, large-scale, long-term peer-reviewed literature
that shows the request to be an effective and/or safe treatment for the noted pathology.
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity
of this request as an exception to guidelines. Our physician reviewer found that the enrollee's condition does
not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve bone marrow aspiration for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 30, 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on September 18, 2020.
You asked the Plan to pay for the testing services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. We looked at the file and Medicare rules. The services at issue were billed with the Mobile Unit POS code 15, but the records show that they were provided to serve an entity for which another POS code exists. Therefore, we decided that the Plan does not have to pay for the testing services provided on September 18, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 28, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, predictive screening, was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay
for the laboratory services rendered on January 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on March 24, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 99253 is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 27524 is 1, The MAI value for this code is 2. The file shows that 2 units of this code was billed for the same provider on the date of service at issue, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery and rehabilitation evaluation services provided from December 7, 2020, to December 8, 2020.
You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you feel that this surgery should be considered inpatient. The Plan denied your request. The Plan says the cost-sharing amount you are being charged is correct.
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 4% coinsurance for in-network outpatient hospital services. Your patient status for this hospital stay was outpatient; therefore, the outpatient hospital coinsurance applies to this claim. The allowed amount of the claim is $12,024.69, resulting in a coinsurance amount of $480.99.
You have been asked to pay 4% coinsurance for outpatient hospital services. Outpatient hospital services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for outpatient surgery and rehabilitation evaluation services provided from December 7, 2020, to December 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of adult partial hospital program days from June 2, 2021, through June 9, 2021.
You asked the Plan to pre-approve continuation of adult partial hospital program days. You say that you could benefit from extended treatment. The Plan denied your request. The Plan says additional partial hospital program days beyond the approved 20 days from May 3, 2021, through June 1, 2021 is not medically necessary.
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 continuation of adult partial hospital program days. Our reviewer says that the requested continuation of adult partial hospital program days are not considered medically reasonable and necessary in this case. Our physician reviewer found that based upon review the records provided you were not showing any dangerousness to self or others and not showing any perceptual disturbance or psychosis. You were cooperative with care. In terms of Risk of Harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to
Functional Status, the records support a score of 1 due to no problems with impairment. In terms of Medical, Addictive and Psychiatric Comorbidity, the records support a score of 1 due to overall medical stability. In terms of level of stress of the Recovery Environment, the records support a score of 1 due to a stable living situation. With regards to Level of Support for the recovery environment, the records support a score of 1 due to availability of treatment resources. With regards to Treatment and Recovery History, the records support a score of 1 due to no history of previous success at the partial hospital treatment center level of care. In terms of Engagement and Recovery Status, the records support a score of 1 due to cooperation in treatment and insight into your need for treatment along with insight into your treatment needs. Thus, you have a composite score of 7. This correlates with treatment in a community-based outpatient clinic setting. All told, the requested partial hospitalization program services are not medically necessary for your treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of adult partial hospital program days have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of adult partial hospital program days from June 2, 2021, to June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these 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 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 an office visit provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the alcohol and/or substance abuse structured screening (99409) provided on November 23, 2020 to December 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the behavioral health services. You say that you were told the Plan would cover 1 evaluation and 4 counseling sessions per year. You were told the Plan would cover your claim with the information provided. The Plan denied your request. The Plan says a licensed mental health counselor is not part of the the Medicare program. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
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 the alcohol and/or substance abuse structured screening (99409) provided on November 23, 2020 to December 11, 2020 by an out of network (OON)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary compressed gas oxygen system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare policy does not cover additional or emergency oxygen systems, because it is not considered a medical necessity.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep. 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 system. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found it appears the request is for a stationary oxygen tank, for preventive or precautionary purposes. It is unclear whether the enrollee has a home oxygen concentrator. The Sp02 of 86% during activity supports a medical need for supplemental oxygen during sleep and with activity, which would be met with a stationary oxygen concentrator and portable tanks. A stationary O2 tank is not medically necessary and does not meet Medicare criteria for home oxygen. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a stationary compressed gas oxygen system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup services you received on March 29, 2021.
You asked the Plan to pay for the core buildup services. The Plan denied your request. The Plan says this is not a covered benefit.
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 services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Core buildup is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the core buildup services you received on March 29, 2021.