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

We decided that the Plan does not have to pre-approve wound care supplies.
You asked the Plan to pre-approve wound care supplies. You say that you need these supplies for your sores and would not be able to function throughout the day without them. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because you do not have a qualifying wound for these supplies.
The Plan follows Medicare rules. Medicare rules say that wound care supplies are only covered by Medicare when the enrollee has a qualifying wound. 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 wound care supplies. Our reviewer says that you do not meet the Medicare criteria for the requested wound care supplies. Our physician reviewer found you are noted to have chronic, bilateral, lower extremity wounds. There is no evidence that you have these wounds due to surgery or debridement. Therefore, the requested wound care supplies do not meet coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wound care supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve wound care supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Philips SmartSleep Snoring Relief Band.You asked the Plan to pre-approve a Philips SmartSleep Snoring Relief Band. You say that you want this device for positional sleep training.The Plan denied your request. The Plan says this item is not used to take care of a medical need.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 Philips SmartSleep Snoring Relief Band.
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 the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says based on a review of peer reviewed literature for the use of bone marrow aspirate in spinal fusions, there is no high-level medical evidence that the use of bone marrow aspirate increases fusion rates in cases such as this enrollee.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 17,
2019 through August 21, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found based on the documentation provided this hospitalization does not qualify for
inpatient payment under the two-midnight rule. The enrollee was evaluated in the emergency department (ED)
on August 17, 2019 for failure to thrive, weakness and falls. He was found to have no significant illness or
injury. While further evaluation was reasonable, the enrollee could have been placed on observation status to
undergo such observation. As is, no significant medical issues were identified.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from August 17, 2019 through August
21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on November 15, 2019.
You asked the Plan to waive the copayment for the MRI. You say that it is not fair that insurance only paid $39. You say that it is hard for you to pay $225. The Plan denied your request. The Plan says the copayment 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 a $225 copayment for diagnostic radiology. 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 for the MRI provided on November 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided on September 10, 2018. You asked the Plan to pay for physician services. You say that you are requesting approval of payment for this claim. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.
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 physician services was not filed until September 27, 2019. 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 surgical services provided on September 10, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services at 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 physician's services provided on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings (D0274) provided on November 18, 2019.You asked the Plan to pay forthe bitewings. You say that you were told by a customer service representative that a full set of panoramic x-rays would have been covered, but bitewings were not. You also say that you feel the x-rays should be covered.The Plan denied your request. The Plan says this 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 forthe bitewings (D0274) provided on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from October 24, 2019 through October 30, 2019.You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary.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 inpatient hospital care have not been met. The inpatient stay is denied because the patient had exhausted the hospital benefit of 120 days along with the lifetime hospital benefit of 30 days already.Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from October 24, 2019 through October 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 4, 2019 to September 6, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says payment is not allowed for this service because it was billed with an incorrect type of bill code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information,we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted with an invalid type of bill. Final Home Health claims must be submitted with TOB 0329. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 4, 2019 to September 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Chest (71550).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.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 coverage criteria has not been met. Our physician reviewer found the enrollee is experiencing acute post thoracotomy pain. The enrollee had a computed tomography scan of the chest without new findings. An MRI was subsequently order. The documentation does not outline clinical concern or a differential diagnosis to be considered with an MRI study.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 not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Chest (71550).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from November 28, 2019 to November 30, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you are normally only charged a $250 copayment.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, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay a $425 copayment per admission for inpatient hospital care. You have been asked to pay a $425 copayment per admission for an inpatient hospital stay. An inpatient hospital stayfalls 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 foran inpatient hospital stay provided from November 28, 2019 to November 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the meningicoccal conjugate immunization provided on December 10, 2019.
You asked the Plan to pay for the immunization. You say that you were told this would be covered. The Plan denied your request. The Plan says that this is not covered under Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the immunization. Therefore, we decided that the Plan does not have to pay for the meningicoccal conjugate immunization provided on December 10, 2019.
Benefits for the immunization 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bronchoscopy surgery services (Zephyr procedure).
You asked the Plan to pre-approve Zephyr procedure. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because this procedure is considered experimental/investigational.
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 Zephyr procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there have now been several large well-designed clinical trials demonstrating the significant effectiveness of this procedure for patients with severe chronic obstructive pulmonary disease (COPD), heterogenous emphysema, and significant air trapping. There is enough clinical evidence about the potential risks and benefits of the procedure that it is no longer considered experimental. The enrollee has heterogenous emphysema with predominance in the upper lobes and has no contraindications to the procedure. This procedure must be done as an inpatient with a minimum 3-day hospital stay, because of the risks. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zephyr procedure have been met. Therefore, we decided that the Plan has to pre-approve bronchoscopy surgery services (Zephyr procedure).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for six extractions and dentures provided on November 26, 2019.
You asked the Plan to pay for these services. You say that The Plan denied your request. The Plan says that your request exceeds the plan 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. The Plan covers two extractions per calendar year. We looked at the file and Medicare rules. The file indicates the plan has already provided coverage for two extractions this year. Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are not among those covered under this benefit. 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 six extractions and dentures provided on November 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing care (99309) provided on September 2, 2019 by provider NP.You asked the Plan to pay forthe nursing care. You say that services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or pre-authorized.Medicarerules 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 forthe subsequent nursing care (99309) provided on September 2, 2019 by provider, NP.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation rendered to the enrollee from November 25, 2019 to December 11, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0283 was not billed with an appropriate modifier. The Plan must follow Medicare rules. Medicare rules say that always therapy codes must be billed with a therapy modifier. We looked at the file and Medicare rules. The file shows that code G0283 was not billed with the required therapy modifier. 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 electrical stimulation rendered to the enrollee from November 25, 2019 to December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide upgraded electronics.
You asked the Plan to provide the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs the upgraded electronics to increase ease, safety and independence. The Plan denied your request. The Plan says the electronic upgrades cannot be covered as it is not medically necessary to control the three approved power options through the joystick (drive interface).
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Documentation shows that the enrollee has normal range of motion and 4/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met. Therefore, we decided that the Plan does not have to provide upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to enrollee on November 24, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99359 is 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 99359 is prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (List separately in addition to code for prolonged service).We find that CPT code 99359 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. 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 services rendered to enrollee on November 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from December 6, 2019 to December 30, 2019.You asked the Plan to waive the copayments for the physical therapy visits. You say that you did not have as many visits that you were billed for. You say your copayment is too high. 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 $40 copayment for each in-network Medicare-covered therapy visit. You have been asked to pay $40 copayment for the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the physical therapy visits provided from December 6, 2019 to December 30, 2019.