Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a podiatry visit and diabetic shoe inserts
provided October 13, 2020.
You asked the Plan to waive the copayments for the podiatry visit and diabetic shoe inserts. You say that there
should be no copayment for podiatry services. The Plan denied your request. The Plan says there is no
copayment for routine podiatry visits. The office visit at issue was not a routine exam, it was a shoe fitting. The
correct cost-sharing was applied.
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 $30
copayment for office visits and a 5% coinsurance for diabetic shoes.
You have been asked to pay a $30 copayment for the podiatry office visit, and a 5% coinsurance for diabetic
shoe inserts. 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 a podiatry visit and diabetic shoe inserts
provided October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on
May 1, 2020.
You asked the Plan to pay for the therapeutic activities services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, four units of this code were
billed. The documentation does not support the units billed (of each 15 minutes). The documentation does not
support that at least a minimum of 53 minutes was spent providing this therapy service on this date of service.
Based on this information, we decided that Medicare rules for coverage of the therapeutic activities services
have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities
services coded 97530 provided on May 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3 additional skilled nursing visits.You asked the Plan to pre-approvethe 3 additional skilled nursing visits. You say that you had aortic valve replaced. You say that your doctor ordered home health to monitor your post-surgical progress including, checking vitals, blood tests, and inspecting incisions.The Plan denied your request. The Plan says the skilled nursing visits were ordered to teach you about disease and medication management. The Plan also says that the 3 additional skilled nursing visits are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 3 additional skilled nursing visits. Our reviewer says that the 3 additional skilled nursing visits are not medically necessary. Our physician reviewer found additional skilled nursing services are not required to effectively provide treatment, care, or services in order to improve your condition, or to establish or perform a maintenance program to maintain your condition or prevent deterioration. The reviewer found that you have been instructed in disease process, are medically stable without significant complications and without infection or incision complication. Therefore, the reviewer found that there is no complex wound care or other skilled nursing need.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 3 additional skilled nursing visits have not been met.Therefore, we decided that the Plan does not have to pre-approve3 additional skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided from June 10, 2020, to September 23, 2020.
You asked the Plan to pay for home infusion therapy services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this procedure code is not valid for Medicare purposes.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes established for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy services provided from June 10, 2020, to September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided the Plan does not have to pay for a power mobility device purchased out of network on May 17, 2019.
You asked the Plan to pay for this equipment. You say that the Plan should pay for this equipment as it was
medically necessary. The Plan denied your request. The Plan says that you purchased this equipment out of
network without prior authorization. We administratively overturned the Plans denial because a 2019
Evidence of Coverage (EOC) had not been submitted with the case file. The Plan requested a reopen and
provided the required EOC.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. Medicare does not cover power mobility equipment that is purchased. Medicare only covers power
mobility equipment when specific physician documentation is provided. 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 Plan contract says that durable medical equipment requires prior
authorization.
You purchased a power mobility device out of network and without prior authorization. Medicare only covers
power mobility equipment that is rented. The provider is not a network provider with the Plan. The Plan had network providers available who could have provided a power mobility device for rent if you met
the required physician evaluation criteria for this equipment. The Plan did not pre-approve this purchase. We
found no exception that would require the Plan to pay for this equipment. Therefore, we decided that the Plan
does not have to pay for a power mobility device purchased out of network.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnostic evaluations (90792) provided March 11, 2019.
You asked the Plan to pay for the psychiatric services. You say that you did not receive proper notice of this
enrollee's benefit determination, hence, the untimely submission of the claim. The Plan denied your request.
The Plan says this claim was received past the allowed twelve-month timeframe.
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 psychiatric services was not filed until August 27, 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 psychiatric diagnostic evaluations (90792) provided March 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe PCD (CPT Code E0675)provided to the enrollee from June 26, 2020, through July 21, 2020.You asked the Plan to pay forthe PCD. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decidedthat Medicare rules for coverage of the PCD have not been met. The enrollee had foot surgery and these devices were used to prevent blood clots. The doctor states in the medical record that the enrollee had surgery on June 24, 2020 and this device was used to help prevent blood clots during and after their operation. The correct coding for this device for prevention of deep venous thrombosis is E0676. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay forthe PCD (CPT Code E0675) provided to the enrollee from June 26, 2020, through July 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided from June 2, 2020, through October 23, 2020.You asked the Plan to pay for the nursing facility care. The Plan denied your request. The Plan says that generally speaking, the enrollee must use network providers to receive covered care.  However, areexceptions that arebenefits for use of out-of-network providers for emergency care provided in a hospital emergency room worldwide, urgently needed services as are commonly provided in a urgent care center and out-of-area renal dialysis received from any Medicare-certified dialysis provider throughout the U.S., or if the enrollee is in need of specialized care that is not available within the plan's provider network when such care is prior authorized in advance bythe Plan.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 servicesat 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 nursing facility care provided from June 2, 2020, through October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and
cellphone/media device holder (K0108) for the enrollee.
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan
denied your request. The Plan says that these items do not serve a primary medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and cellphone/media
device holder (K0108) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on December 11, 2019, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that per documentation Hospice was revoked on December 10, 2019.The Plan denied your request. The Plan says the enrollee was enrolled in hospice on November13, 2019 and discontinued on December 10, 2019.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on December 10, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee on December 11, 2019, by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foracupuncture services provided on September 11, 2020 and September 17, 2020 orprovide additional services in 2020.You asked the Plan to pay forthe acupuncture services or provide additional services in 2020. You say that you need the services covered because of your medical condition.The Plan denied your request. The Plan says youmet the acupuncture visits benefit limit of 12 visits per year.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, you have already received 12 sessions for a condition other than CLBP. Therefore, we decided that the Plan does not have to pay foracupuncture services provided on September 11, 2020 and September 17, 2020 orprovide additional services in 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional intraoral periapical x-ray provided on August 17, 2020.You asked the Plan to pay forthe additional intraoral periapical x-ray. You say that you feel that you should not be responsible for the payment.The Plan denied your request. The Plan says benefits for this service have been satisfied.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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on August 17, 2020, and your intraoral x-rays benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe additional intraoral periapical x-ray provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided on May 27, 2020.
You asked the Plan to waive the copayment for the biopsy. You say that you had to go the hospital for two
separate procedures due to COVID. You say you cannot afford the pay the second bill for the biopsy. The Plan
denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295
copayment for each Medicare-covered surgery or other services provided to you 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 $295 copayment for the biopsy. The biopsy falls 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 copayment for the biopsy provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on March 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this appeal 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.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 haveprovided 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 forphysician services provided on March 6, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion Interspinous device (22870, 22869).You asked the Plan to pre-approvea Vertiflex Superion Interspinous device. 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 items andservices 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 a Vertiflex Superion Interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical condition.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 Vertiflex Superion Interspinous device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion Interspinous device (22870, 22869).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the new patient office or other outpatient visit (99203) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that the Plan's in-
network providers are located too far away. The Plan denied your request. The Plan says that they have 
providers who can manage your medical problems. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollee's home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers 
located within reasonable distance and travel time from your home who can provide the new patient office or 
other outpatient visit. Under Medicare rules, this means that contract providers are not accessible to you. 
Therefore, we decided that the Plan has to pre-approve the new patient office or other outpatient visit (99203) 
to be provided by an out of network (OON) provider.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 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's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the patient's functional status or activity tolerance  requires an intensive rehabilitation therapy 
program provided in an IRF. 
 
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 IRF admission and services.