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

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 17, 2020.You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room during the length of the procedure.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe upper partial denture with a flexible base (D5225) provided on December 30, 2019.You asked the Plan to reimburse you forthe dental item. You say that you saw the provider in this case because your regular dentist was not in. You say that you were never advised by anyone that the provider in this case was not a network provider.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says care rendered by a provider that is not part of our supplemental dental network is 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, dental services that you receive from out of network providers are not covered.Therefore, we decided that the Plan does not have to reimburse you forthe upper partial denture with a flexible base (D5225) provided on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier (A9270). 
 
You asked the Plan to pre-approve an air purifier. You say that you have asthma and sinus and has a neighbor that smokes and it is affecting your health. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
The item 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. Therefore, we decided that the Plan does not have to pre-approve an air purifier (A9270).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee would benefit from being in a SNF.The Plan denied your request. The Plan says the enrollee does not need more skilled therapy, more complicated medical care, complicated wound care that cannot be done by e a nurse at home, or antibiotics through the veins that cannot be done by a nurse at home. The plan says that the care needed can be provided at home, with help.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF whenthe four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care, a need new enteral feedings or other SNF level need. The enrollee's functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment at a SNF level. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" given her significant endurance issues. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert (A9280).You asked the Plan to pre-approve a Life Alert. You say that your doctor has recommended this because you have had 15 falls in one month. You have already purchased the Life Alert but is paying $49.99 per month and you feel the plan should cover it.The Plan denied your request. The Plan says this item is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item 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.Therefore, we decided that the Plan does not have to pre-approve a Life Alert (A9280).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexilant.
You asked the Plan to pre-approve Dexilant. You say that the enrollee has tried alternatives, but they do not work. The Plan denied your request. The Plan says Dexilant to be taken at home is not covered under the Part B benefit.
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 Dexilant.
Benefits for Dexilant 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 18, 2020 to January 24, 2020 and from January 27, 2020 to January 31, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 18, 2020 to January 24, 2020 and from January 27, 2020 to January 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a non-routine blood draw (CPT 36410) provided on October 29, 2019.
You asked the Plan to pay for the non-routine blood draw. You say that the procedure was rendered in the appropriate place of service and the claim should be reprocessed for payment. The Plan denied your request. The Plan says any service performed in an inpatient confinement is considered to be performed in an inpatient setting.
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 36410 is not supported in the medical record. Specifically, this code was billed with a place of service code of 22, which represents the place of treatment being an outpatient hospital. The records show that the enrollee was admitted as inpatient on the date of service in dispute. Based on this information, we decided that Medicare rules for coverage of the non-routine blood draw have not been met. Therefore, we decided that the Plan does not have to pay for a non-routine blood draw (CPT 36410) provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on January 13, 2020 to
January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when
provided by an OON 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 has network providers
available who can provide 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 the chiropractic services provided on January 13,
2020 to January 23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Etonogestrel implant system (J7307) provided on October 11, 2019.You asked the Plan to pay forthe Etonogestrel implant system. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says Medicare guidance says procedure code J7307 has a status code of I.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 J7307 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code J7307 has a status code of I. This means that CPT code J7307 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the Etonogestrel implant system have not been met.Therefore, we decided that the Plan does not have to pay fora Etonogestrel implant system (J7307) provided on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that you say you need a power mobility device. The Plan denied your request. The Plan says your assessment shows you are able to walk in your home with the use of your cane or walker.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care on February 1, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be held
responsible for the copayment applied to the claim for the first day of admission. You state you were not placed
into a room until the evening. The Plan denied your request. The Plan says the claim was processed
accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of your medical record shows that the provider advised your health plan of formal admission at 1:54
PM on February 1, 2020. Therefore, you are asked to pay a $305 copayment for the inpatient hospital care.
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 inpatient hospital care on February 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Positron Emission Tomography (PET) scan (78815) provided December 9, 2019.You asked the Plan to pay forthe PET scan. You say that the service was medically necessary and correctly billed.The Plan denied your request. The Plan says the claim did not include an appropriate diagnosis code.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 78815 is not supported in the medical record. Specifically, the claim did not include an appropriate primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met.Therefore, we decided that the Plan does not have to pay fora Positron Emission Tomography (PET) scan (78815) provided December 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the MRI provided on December 23, 2019.
You asked the Plan to waive the copayment the MRI. You say that you would like to appeal the $218.10 billing
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 $225
copayment for each in-network Medicare-covered diagnostic radiology service. For this date of service, you
have been asked to pay the allowed amount of the claim because this amount is less than the $225 copayment
for the MRI.
You have been asked to pay a $225 copayment for the MRI. The MRI falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" 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
the MRI provided on December 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora the CT scan provided on February 13, 2018.You asked the Plan to waive the coinsurance for the CT scan. You say that you disagree with the coinsurance because you went to a free standing facility and not a hospital. 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 20% coinsurance for each radiological diagnostic service, not including x-ray performed at a freestanding radiological facility or physician's office. You have been asked to pay $81.62 which is 20% of the allowed amount for the CT scan. The allowed amount is $408.10. ($408.10 x 20% = $81.62). The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received the CTscan at a freestanding facility. 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 CT scan provided by on February 13, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray and the echocardiogram provided on February 12, 2020.
You asked the Plan to waive the copayment for the chest x-ray and the echocardiogram. You say that the hospital is not an outpatient and it should not be listed as such. 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 $100 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a total of $100 copayment for the chest x-ray and the echocardiogram. The chest x-ray and the echocardiogram fall within the "Outpatient tests and therapeutic services and supplies" hospital 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 chest x-ray and the echocardiogram provided on February 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services (G0299).
You asked the Plan to pre-approve continued home health services. You say that continued services are medically necessary. The Plan denied your request. The Plan says the enrollee does not have skilled needs.
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 continued home health services. Our reviewer says that the criteria for coverage of the requested services has not been met. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. There is no evidence of IV antibiotics, complex wound care, or other skilled nursing needs. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. The documentation does not reveal significant specific functional deficits that require skilled therapy 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 continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services (G0299).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guidance for central venous access device placement (77001) provided on July 22, 2019.
You asked the Plan to pay for fluoroscopic guidance. 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 support the services billed.
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 77001 is fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure). We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for fluoroscopic guidance. Our reviewer says that CPT code 77001 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) billed with a 59 modifier being performed on July 22, 2019, therefore this service cannot be validated.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fluoroscopic guidance have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance for central venous access device placement (77001) provided on July 22, 2019.