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

We decided that the Plan does not have to provide the model specific flex foot system. 
 
You asked the Plan to pay for all lower extremity prostheses, flex foot system (L5980). You say that the 
enrollee needs this brand of a flex foot system due to excessive weight. The Plan denied your request. The Plan 
says the requested foot does not have an authorization from Pricing, Data Analysis and Coding (PDAC). 
 
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 his flex foot system is not authorized by the contractor for CMS. Based on this information, we decided
that Medicare rules for coverage of all lower extremity prostheses, flex foot system (L5980) have not been met. Therefore, 
we decided that the Plan does not have to provide the model specific flex foot system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.

You asked the Plan to pre-approve these services. You say that you disagree with the denial.. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-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 services are not medically necessary. Our physician reviewer found the records show that you have paraplegia from spinal cord compression. The records do not show you have severe arthritis of the hip or knee. The records do not show that a seat lift mechanism will improve or stop deterioration of your condition. You are able to perform a stand pivot transfer with assistance. The criteria for coverage of a seat lift mechanism are not met and the services are therefore not reasonable or medically necessary. 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. A power seat elevation system is also not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve intensity modulated radiation treatment delivery (IMRT).

You asked the Plan to pre-approve intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex (77386 x 30 units). You say that radiation therapy will exceed heart and lung constraints unless IMRT is used. The Plan denied your request. The Plan says that nothing has been presented in the case to indicate that tissue dose reduction is not able to be completed with 3D techniques.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex (77386 x 30 units). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this is it plausible that with IMRT there would be a clinically meaningful benefit. My decision is favorable as IMRT would be furnished in accordance with accepted standards of care, conceding that no actual treatment plan was provided.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex (77386 x 30 units) have been met. Therefore, we decided that the Plan has to pre-approve intensity modulated radiation treatment delivery (IMRT).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, electronic connection, expandable controller harness and a power seat elevation feature.
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 are not needed for a single power option wheelchair.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature.
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 items. Our reviewer says that an expandable controller, electronic connection and expandable controller harness are not considered medically reasonable and necessary in this case. The documentation does not reveal that you require other types of proportional input devices or non-proportional input devices. You do not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. Your strength in the upper extremities and function supports that you can operate any power options through their own individual switches. Our physician reviewer found that your condition does not meet criteria for coverage of an expandable controller, electronic connection and expandable controller harness. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, electronic connection, expandable controller harness and a power seat elevation feature.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says IRF admission 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 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 the complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this member will be able to fully participate in and benefit from the 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 inpatient rehabilitation facility (IRF) admission and services.
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 enrollee needs close medical supervision of inpatient acute rehabilitation. The Plan denied your request. The Plan says you do not require an interdisciplinary team approach for rehabilitation 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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her medical problems are stable. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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 pre-approve the limbal relaxing incision procedure to correct astigmatism.
You asked the Plan to pre-approve the limbal relaxing incision procedure to correct astigmatism. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says this is not a Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are not eligible for coverage under Medicare rules. Therefore, we decided that the Plan does not have to pre-approve the limbal relaxing incision procedure to correct astigmatism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from April 15, 2021, to April 19, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that coronavirus related services would be fully covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $310 copayment for days 1-7 for inpatient hospital care.
You had an inpatient hospital stay from April 15, 2021, to April 19, 2021. The coronavirus waiver expired on January 1, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total amount you owe is: $310 (copayment) x 4 (inpatient days) = $1,240. You have been asked to pay the total copayment amount of $1,240 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from April 15, 2021, to April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110) and each additional intraoral periapical x-ray (D0230) provided on April 19, 2021.
You asked the Plan to pay for the palliative (emergency) treatment of dental pain and each additional intraoral periapical x-ray. You say that nothing was done inside your mouth at this office visit aside from two x-rays. The Plan denied your request. The Plan says palliative (emergency) treatment of dental pain is not a covered service. The Plan also says that your benefits for the additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded.
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, palliative (emergency) treatment of dental pain (D9110) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray on April 19, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110) and each additional intraoral periapical x-ray (D0230) provided on April 19, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 24, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair or shower bench.
You asked the Plan to pre-approve a shower chair or shower bench. You say that you need this item for stability in the shower. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair or shower bench.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 5, 2021, to April 8, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you had surgery and were given medications to take home. You also say that you did not know that you would be responsible for the cost. The Plan denied your request. The Plan says the medication given during hospital services are not covered by Medicare.
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 pay for the self-administered drugs provided from April 5, 2021, to April 8, 2021. Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on December 2, 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 99152 and 99153 are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. The definition of code 99153 is moderate sedation services by other qualified health care professional not performing a procedure, each additional 15 minutes. 

We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's consciousness and physiological status for the first 15 minutes and and additional 15 minutes. 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 moderate sedation services rendered on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2-surface amalgam (D2150) provided on April 15, 2021.
You asked the Plan to pay for the dental service. You say that you feel this service is considered preventive. You say that you are on a fixed income. You say that the coronavirus has put a hardship on you. You also say that in 2019 amalgams were covered at 50%. The Plan denied your request. The Plan says amalgam is not listed and therefore is not a covered service. The Plan also says that you did not contact them prior to receiving the service to verify benefits and provider eligibility.
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 amalgam is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2-surface amalgam (D2150) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 14, 2021 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 by the member's primary care physician.
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 April 14, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided by Stephanie Boyle on April 12, 2021.

You asked the Plan to pay for periodontal maintenance. You say that this was a regular cleaning not a deep cleaning. You say that you are entitled to two cleanings per year. The Plan denied your request. The Plan says the service 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance provided by Stephanie Boyle on April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan of the maxillofacial area you had on June 18, 2020.
You asked the Plan to waive the copayments for the CT scan. You say that you believe copayments were waived, so you would like these copayments removed. The Plan denied your request. The Plan says these copayments were charged correctly. The Plan also says that from May 11, 2020, to September 30, 2020, they waived certain copayments. However, the Plan states that cost sharing for radiological diagnostic services were never part of the waiver program.
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 $160 copayment for radiological diagnostic services.
You have been asked to pay a a $160 copayment for the CT scan. There was no copayment waiver in effect on this date of service that included radiological tests such CT scans. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan of the maxillofacial area you had on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on December 2, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered by Medicare for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided on December 2, 2020