Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you received at an outpatient hospital on October 15, 2021.
You asked the Plan to waive the copayment for the TTE. You say that you don't think you should have to pay this copayment because the results were unable to show your heart relaxing. As a result, you had to have a pulmonary function test. The Plan denied your request. The Plan says you were charged this copayment 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 $125 copayment for diagnostic procedures and tests in any location other than a physician's office.
You have been asked to pay a $125 copayment for the TTE. The TTE falls within the diagnostic procedures and tests in any location other than a physician's office benefit category. This copayment applies regardless of the results of this test. 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 transthoracic echocardiography (TTE) you received at an outpatient hospital on October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and related accessories.

You asked the Plan to pre-approve an ultralightweight wheelchair. You say that this specific ultralightweight wheelchair is medically necessary. The Plan denied your request.

The Plan says ultralightweight wheelchair appears to exceed the enrollee's needs.

The Plan follows Medicare rules. Medicare rules say that an ultralightweight wheelchair is subject to the coverage criteria listed 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 an ultralightweight wheelchair. Our reviewer says that the requested ultralightweight wheelchair is not medically reasonable and necessary. Our physician reviewer found that the criteria for the ultralightweight wheelchair coded as K0005 have not been met. The documentation does support that the patient has a mobility deficit that impairs mobility related activities of daily living in the home. The documentation does not support that this mobility limitation is unable to be effectively met with a standard wheelchair. The mobility and seating assessment notes that a K0001-K0007 could meet his functional needs. The documentation is not clear that the patient has the cognition to independently operate the requested wheelchair as the medical progress note indicates a review of systems could not be obtained due to cognitive deficits. The documentation does not support that the patient does not have an attendant that is unable to propel the patient in a standard wheelchair. The documentation does not reveal that the requested ultralight wheelchair (K0005) and accessories is medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultralightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and related accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for
LTACH care. The Plan denied your request. The Plan says the enrollee does not need daily complex wound
care that needs intensive nursing care or on-site specialty services. The Plan says that the level of care provided
in an LTACH setting is more than the enrollee's medical conditions need.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital.
The enrollee does not require services at the LTACH that are not available at the acute care hospital where she
is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on July 28, 2021, to August 12, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $275 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $275 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,375 ($275 x 5 days = $1,375). The correct copayment has been applied to the inpatient hospital stay that was provided. 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 by a participating provider on July 28, 2021, to August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 28, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. 

We looked at the file and Medicare rules. Billed procedure code 99214 (office visit) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70544) provided on June 30, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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, we have confirmed that code 70544
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the services (70544) provided on June 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla tablets.
You asked the Plan to pre-approve Otezla tablets. You say that Otezla is medically necessary for the enrollee for the treatment of psoriasis. The Plan denied your request. The Plan says Otezla is a self-administered drug and does not fall under Part B coverage.
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 Otezla tablets.
Benefits for Otezla tablets 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services received on March 2, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 97164-GP, KX (1 unit) remains 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 97164 is "Re-evaluation of physical therapy established
plan of care, requiring these components: An examination including a review of history and use of standardized
tests and measures is required; and Revised plan of care using a standardized patient assessment instrument
and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the
patient and/or family."
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 the services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found a physical therapy assistant (PTA)
would not perform a re-evaluation. PTAs are skilled health care workers who provide services under the
direction and supervision of PTs and implement certain aspects of treatment plans that are outlined by PTs.
PTAs are not permitted to perform evaluations, assessment procedures, or certain complex procedures; nor do
they design plans of care or develop treatment plans. Additionally, the documentation supports a home visit, so
there is a more appropriate code to use for home visits.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for physical therapy services received on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vaccine provided on May 24, 2021.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered service.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. 

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the vaccine provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and amalgams (D2140 and D2150) provided on June 16, 2021, and July 20, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and amalgams. You say that this treating provider is not a Medicare participant, but the Plan's booklet states that non-Medicare is covered by the Plan. The Plan denied your request. The Plan says these services were rendered by a provider who chose not to receive Medicare funds. The Plan also says that if you use a provider that has opted out of Medicare you will not receive reimbursement.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and amalgams (D2140 and D2150) provided on June 16, 2021, and July 20, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and incisional biopsy of oral tissue (D7285) provided on June 25, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the problem focused limited oral evaluation and incisional biopsy of oral tissue. You say that it makes no sense that a non-Medicare covered procedure needed to be performed by a participating Medicare dentist because it was not clarified in the benefit details. You also say that it should have been stated that non-Medicare services were covered, but had to be performed by a participating dentist. The Plan denied your request. The Plan says these services were rendered by a provider who chose not to receive Medicare funds.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and incisional biopsy of oral tissue (D7285) provided on June 25, 2021 by a Medicare opt out provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 11, 2021, to August 19, 2021, and October 19, 2021, to October 25, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are on a fixed income, and you cannot afford this. The Plan denied your request. The Plan says the correct copayments have been 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 $350 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.

You have been asked to pay a $350 copayment per day for days 1-5. There is a $0 copayment for additional days for each inpatient hospital stay. The amount you are being asked to pay per visit is $1,750 ($350 x 5 days = $1,750). The total amount you are being asked to pay is $3,500 ($1,750 + $1,750 = $3,500). 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 by a participating provider on August 11, 2021, to August 19, 2021, and October 19, 2021, to October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 14, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 16, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that the physician sent the specimens to you to
provide the testing. The Plan denied your request. The Plan says that both the referring provider and the
provider doing the laboratory services are both non-participating providers.
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 laboratory services provided on September 16,
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to a LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. You are
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are
not available at the present setting where you are currently receiving care. There are no services available at the
LTACH that you require that are not available at the health care setting being offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Hizentra.
You asked the Plan to pre-approve Hizentra. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not
been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Hizentra.
Benefits for Hizentra may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.