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

We decided that the Plan does not have to pre-approve expandable controller, expandable controller harness, and electronic connection between systems.

You asked the Plan to pre-approve expandable controller, expandable controller harness, and electronic connection between systems. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are only covered for certain indications. 

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 expandable controller, expandable controller harness, and electronic connection between systems. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities supports that the enrollee can control any power options through their own individual switches. Therefore, the enrollee does not meet criteria for the requested items. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller, expandable controller harness, and electronic connection between systems have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller, expandable controller harness, and electronic connection between systems.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on April 6, 2021.
You asked the Plan to waive the copayment for the ambulance ride. You say that you could not walk or sit when you were discharged from the hospital. You say this was a necessary transport. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for each out-of-network Medicare-covered one-way trip via ground ambulance, after you pay your $1,500 deductible. You have been asked to pay a $275 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The record shows your ambulance ride was non-emergent. 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 ride provided on April 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 11, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when the paramedics arrived, they helped you up, examined you, and recommended that you go to the hospital. You also say that you declined going to the hospital because you were exhausted, and this was a medical emergency that required first responders. The Plan denied your request. The Plan says this service is not covered. The Plan also says that if there is no transport, then there is no Medicare-covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on March 11, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alveoloplasty (D7310).

You asked the Plan to pre-approve the alveoloplasty. You say that the surgery was denied but you have insurance. The Plan denied your request. The Plan says the criteria for the alveoloplasty code requested has not been met. The Plan also says that the provider may resubmit the alveoloplasty under code D7311.

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 alveoloplasty code requested is only covered in conjunction with four or more extractions. The records show only two extractions are being provided. Therefore, we decided that the Plan does not have to pre-approve the alveoloplasty (D7310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric car/vehicle.

You asked the Plan to pre-approve an electric car/vehicle. You say that this request is necessary for you to perform errands outside the home. The Plan denied your request. The Plan says this item is not covered for use outside the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve an electric car/vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee is not on insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose
monitor.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on April 9, 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 that the services were not medically necessary.

The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has diabetes and has been prescribed Lantus and Humalog. He is not able to pay for the Humalog so he is taking regular insulin three times per day instead of the Humalog. He was seen on January 28, 2021 and February 9, 2021. He is adjusting his insulin doses based on blood glucose levels and is under close follow up. The criteria for coverage are met; therefore, the CGM supplies are reasonable and 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 been met. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on April 9, 2021.

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 the extractions and deep sedation provided by an opt out provider on August 26, 2020.
You asked the Plan to pay for the extractions and deep sedation. You say that your preferred plan says you do not have to use an in-network provider for non-Medicare covered dental services. The Plan denied your request. The Plan says the Plan cannot make payment for services performed by providers who have opted out of Medicare.
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 pay for the extractions and deep sedation provided by an opt out provider on August 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency ambulance transportation
service (A0425, A0427, A0398) provided on January 11, 2021.

You asked the Plan to waive the copayment for an ambulance transportation service. You say that you were at
an eye appointment when the provider called 911 due to a health condition. You also say that you do not agree
with the charge for not staying in a hospital overnight. The Plan denied your request. The Plan says the
copayment you are being charged is correct.

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 per trip, each way, for ambulance services. This copayment is waived if you are admitted to the
hospital.

You have been asked to pay a $125 copayment for an ambulance transportation service. The EOC confirms
$125 is the required copayment for this service. 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
emergency ambulance transportation service (A0425, A0427, A0398) provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel rendered on May 15, 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 code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on May 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related accessory (E0667).
You asked the Plan to pre-approve a pneumatic compression device and related accessory. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Since the base pneumatic compression device is not eligible for coverage, the related accessory will not be covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related accessory (E0667).
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. The Plan denied your request. The Plan says your ongoing skilled needs can be provided at a lower level of 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 you were admitted to the acute care hospital myocardial infarction and pneumonia. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

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 pay for the bitewing x-rays (D0274) provided on October 29, 2020.
You asked the Plan to pay for the dental service. You say that you were not informed that the plan stopped paying for this service twice per year. You say that you are on a low fixed income. You also say that your dentist would not know if there was a problem if they are not allowed more than 1 x-ray per year. The Plan denied your request. The Plan says bitewing x-rays are covered once per plan year. The Plan also says that the frequency limit 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 and bitewing x-rays are covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on January 24, 2020. Additionally, the record shows that a set of bitewing x-rays was denied in 2019 for frequency limit as well. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) with innerspring
mattress (E0271).
You asked the Plan to pre-approve a total electric hospital bed with innerspring mattress. You say that your
current hospital bed is not meeting your medical needs. The Plan denied your request. The Plan says this is not
a covered item under Medicare.
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. In addition, because the base bed will not be covered the innerspring mattress will not
be covered. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed
(E0265) with innerspring mattress (E0271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the eye exam and refraction provided on April 5, 2021.
You asked the Plan to fully pay for the eye exam and refraction. You say that you went for a normal eye exam but was billed for a medical condition of dry eyes. You say that you were expecting to have the charges covered as your annual eye exam which you are entitled to. The Plan denied your request. The Plan says the copayment applied correctly to the eye exam and the refraction is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a medical eye exam with a $45 copayment and the refraction is only covered as necessary with a non-Medicare covered routine vision exam from a network provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the eye exam and refraction have not been met. Therefore, we decided that the Plan does not have to fully pay for the eye exam and refraction provided on April 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone density study interpretation provided on March 22, 2021.

You asked the Plan to pay for bone density study (77080) interpretation. You say that the services provided were rendered appropriately and doctors must read all films. The Plan denied your request. The Plan says screening bone densitometry is not indicated for males younger than 70 without risk factors for osteoporosis.

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, bone density study (77080) interpretation, 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 bone density study interpretation provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88321) provided on March 17, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value was exceeded.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 the services (88321) provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies materials, and clinical staff time provided on January 18, 2021, February 24, 2021 and March 24, 2021.
You asked the Plan to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (99072). You say that more supplies and materials were used due to the public health emergency. The Plan denied your request. The Plan says code 99072 will be disallowed when billed in conjunction with another procedure code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (99072) has a bundled relationship with code 99212 and cannot be paid as billed. This code has a Status of B, Bundled Code. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies materials, and clinical staff time provided on January 18, 2021, February 24, 2021 and March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214)
provided on December 22, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you were charged for services that
were done by your primary care physician. The Plan denied your request. The Plan says the copayment you are
being charged is correct.
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 $40
copayment for physician/practitioner services, including doctor's office visits with a specialist. Your contract
with the Plan also clearly says that if you use a PCP that is not printed on your ID card, you may incur a higher
cost share, or your claims may be denied.
You have been asked to pay a $40 copayment for an office visit. The Plan confirmed the rendering provider is
not your PCP. The EOC confirms $40 is the required copayment for this service. An office visit falls within the
physician/practitioner services, including doctor's office visits with a specialist 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 office visit with a specialist (99214) provided on December 22,
2020.