Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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. 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 the enrollee 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed.  You asked the Plan to pre-approve a total electric hospital bed. You say that you need this bed to be able to regain the maximum functionality and help with your therapies. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xarelto for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.  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 Xarelto for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oxygen equipment (E1390) purchased on April 6, 2021.  

You asked the Plan to pay for the oxygen equipment. You say that you would like reconsideration because you were not aware that you needed prior authorization and this equipment is medically necessary. The Plan denied your request. The Plan says you did not obtain prior authorization or a physician order.  

The Plan must follow Medicare rules. Medicare rules say that claims for oxygen must also be supported by medical documentation in the patient's record.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. Specifically, the record does not indicate that you obtained prior authorization or a physician order for the purchased equipment. Therefore, we decided that the Plan does not have to pay for the oxygen equipment (E1390) purchased on April 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (procedure code 73564) provided to the enrollee on January 20, 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 the reports submitted are duplicates of each other.

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 73564 is "Radiologic examination, knee; complete, 4 or more views." 

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 there are two reports of the same exam - bilateral four view knee series on January 20, 2021. Thus, the position that the two exams are duplicates is valid. One of the claims has been paid. No additional compensation is warranted.

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 radiology services (procedure code 73564) provided to the enrollee on January 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0428) provided on July 29, 2021.  

You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this bill. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  

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 $250 copayment for ambulance transportation.   

You have been asked to pay a $250 copayment for the ambulance services. 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 ambulance transportation services (A0428) provided on July 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 2, 2021.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Per CMS guidelines Original Medicare Fee for Service retains payment responsibility for all hospice and non-hospice election through the end of the month of the hospice and non-hospice related claims, except for Part D services and supplemental services, from the date of the hospice election through the end of the month of the hospice revocation/election termination.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for an air conditioner purchased on July 13, 2021.

You asked the Plan to provide reimbursement for an air conditioner. You say that you have COPD as well as asthma and need the air conditioned at all times. The Plan denied your request. The Plan says rules for payment have not been met because you do not meet criteria for enrollment in the special supplemental benefit.

The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an air conditioner have not been met. Specifically, you are not enrolled in the special supplemental benefit. Therefore, we decided that the Plan does not have to provide reimbursement for an air conditioner purchased on July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endovenous ablation therapy.  You asked the Plan to pre-approve endovenous ablation therapy. You say that this is medically necessary, and the enrollee is currently wearing compression stockings and has a wound. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not had 3 months of conservative therapy and the requirement for absence of significant peripheral arterial disease is not met.  The Plan follows Medicare rules. Medicare rules state that endovenous ablation therapy may be met under certain clinical conditions.  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 endovenous ablation therapy. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested endovenous ablation therapy. Our physician reviewer found the enrollee has a history of diabetes, severe peripheral arterial disease, and a lateral ulcer of the foot. Formal compression was initiated in November 2021. There has been no reevaluation at the 3-month or greater time point. Currently the documentation does not demonstrate that the patient is having such severe issues from a venous standpoint to be able to determine the appropriateness or medical necessity of ablation. The enrollee also has the presence of an exclusion criterion which is severe peripheral arterial disease.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete (76641) provided July 20, 2021.  

You asked the Plan to waive the deductible for the complete breast ultrasound. You say that the ultrasound was medically necessary and should be included in the cost of the mammogram. The Plan denied your request. The Plan says the cost of this service was correctly applied to your deductible.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $395 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies.   

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $395 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the complete breast ultrasound was received on July 20, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete (76641) provided July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia service (00140) provided on November 16, 2020.  You asked the Plan to pay for the anesthesia service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services rendered.  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 00140 is anesthesia for procedures on eye; not otherwise specified.  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 anesthesia service. Our reviewer says that CPT code 00140 does not meet criteria for billing or reimbursement consideration.  Our reviewer found the anesthesia report is hand written and difficult to translate. The Plan documents anesthesia services were performed for CPT 66984. Per CPT guidelines, procedures should always be coded to the highest specificity.  In this case, a cataract extraction and lens prosthesis was performed.  CPT 00140 is an inappropriate code to report, as a more specific code exist for service performed  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 anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia service (00140) provided on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.

You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because these orthotics were medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2740), prefabricated post and core in addition to crown (D2954), and endodontic therapy (D3320) provided on July 7, 2021.  You asked the Plan to pay for the crown, prefabricated post and core, and endodontic therapy. You say that your plan includes coverage of $500 for preventive and comprehensive services. You also say that the remaining $175 of your allowance should be payable under the crown. The Plan denied your request. The Plan says these services are not covered under your plan.  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 the crown (D2740), prefabricated post and core in addition to crown (D2954), and endodontic therapy (D3320) provided on July 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home infusion therapy (S9367) provided on May 20, 2021, through May 26, 2021.  

You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9367 is not valid for Medicare purposes.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT code S9367 is not supported in the record. Specifically, CPT code S9367 has a status indicator of I. This means that CPT code S9367 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9367) provided on May 20, 2021, through May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 5, 2021 by an out-of-network (OON) provider.  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 were rendered by an out-of-network provider without prior authorization.  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 the laboratory services provided on August 5, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for orthotics (L1960, L2275, L2820) provided on June 22, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for orthotics. You say that you were told authorization was not required. The Plan denied your request. The Plan says authorization is required for out-of-network items and services.  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 orthotics (L1960, L2275, L2820) provided on June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 5, 2021 by an out-of-network (OON) provider.  

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 were rendered by an out-of-network provider without prior authorization.  

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 the laboratory services provided on August 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to provide reimbursement for the medical services provided on June 30, 2021.  

You asked the Plan to provide reimbursement for the medical services. You say that you require bioidentical medicines because anything processed through your liver makes your liver enzymes skyrocket. You feel that this is medically necessary and should be reimbursed. The Plan denied your request. The Plan says you received these services from a provider who has opted out of Medicare. The Plan cannot make payment for these services.  

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to provide reimbursement for the medical services provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical or manipulative therapy performed for maintenance rather than restoration (S8990) provided October 27, 2021.  

You asked the Plan to pay for the chiropractic service. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is not a covered benefit.  

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for physical or manipulative therapy performed for maintenance rather than restoration (S8990) provided October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for infection control supplies provided to the enrollee on June 30, 2021.  You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says these codes are invalid for Medicare purposes.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of the denied codes is:  S1015:  IV tubing extension set  S8301:  Infection control supplies, not otherwise specified  We find that procedure codes S1015 and S8301 is not supported in the medical record. Specifically, these codes has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for infection control supplies provided to the enrollee on June 30, 2021.