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

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental pneumatic appliance (E0667).  

You asked the Plan to pre-approve intermittent limb compression device and appliance. You say that attached is documentation showing that the pump (E0651) and arm attachment (E0667) meets the coverage criteria. The Plan denied your request. The Plan says the request for a pneumatic compression device is not medically necessary.  

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  

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 intermittent limb compression device and appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that all of the requirements listed in the LCD have been met for Medicare coverage. As required by the LCD, records provided do not document all of the following: At a minimum, re-assessments conducted for a trial must include detailed measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental pneumatic appliance (E0667).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on August 22, 2021.  You asked the Plan to pay for the no transport ambulance treatment. You say that the service should be covered. The Plan denied your request. The Plan says this is not a 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 August 22, 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, no transport (A0998), provided on August 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the chemodenervation of muscles provided on March 16, 2021, and July 13, 2021.  You asked the Plan to waive the copayments for the chemodenervation of muscles. You say that you disagree with the service being classified as a surgical procedure. You state that you are not in an operating room and the procedure takes less than ten minutes. You state that the increase in charges is a financial hardship, and this injection is necessary for your quality of life. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities.   The record shows that you received the chemodenervation of muscles at an outpatient hospital facility on March 16, 2021. The chemodenervation of muscles is considered a surgical procedure. Therefore, you are responsible to pay the allowed amount of $446.87, which is less than the $450 copayment.   The record shows that you received the chemodenervation of muscles at an outpatient hospital facility on July 13, 2021. The chemodenervation of muscles is considered a surgical procedure. Therefore, you are responsible to pay the allowed amount of $446.88, which is less than the $450 copayment.  The total amount you owe is: $893.75.   You have been asked to pay the total copayment amount of $893.75 for the chemodenervation of muscles. The chemodenervation of muscles falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 chemodenervation of muscles provided on March 16, 2021, and July 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 9, 2021, to August 7, 2021.  You asked the Plan to pay for the custodial care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says The Plan says that the enrollee did not receive skilled care.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.       We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 9, 2021, to August 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the physical therapy provided on June 17, 2021.  

You asked the Plan to waive the deductible for the physical therapy. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  

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 $750 deductible which applies to Outpatient rehabilitation services.   

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to Outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time the physical therapy was received on June 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the physical therapy provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded as 99072, S8301, A9901, A4649, and A4550 provided on April 16, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services as billed are not covered according to Medicare rules.  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 looked at the file and Medicare rules. In this case, codes 99072 and A4550 have a Status Code of "B" under the Physician Fee Schedule which indicates that they are Bundled Codes whose payment is always bundled into payment for other services not specified. These codes are not separately payable. For code A4649, this has a Status Code of "P" which indicates it is a Bundled/Excluded code where no separate payment will be made. For code A9901, this has a Status Code of "X" which indicates no payment will be made under the Physician Fee Schedule. Finally, code S8301 has a Status Code of "I" which indicates that it is not valid for Medicare purposes as Medicare uses another code for reporting of, and payment for, these services.   Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 99072, S8301, A9901, A4649, and A4550 provided on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 10, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility of the dialysis center.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.     We looked at the file and the rules. The records show that the lab services were related to the enrollee's dialysis treatment. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from June 23, 2021, to June 26, 2021.  

You asked the Plan to pay for the self-administered drugs. You say that this bill should be paid. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.  

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from June 23, 2021, to June 26, 2021.   

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on July 14, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the billed codes are included in the dialysis rate. The Plan denied your request. The Plan says the tests are not separately reportable by the laboratory.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the behind the ear hearing aid, digital, monaural (V5257) provided November 20, 2018.  You asked the Plan to pay for the hearing aids. You say that you didn't know you had hearing aid coverage. The Plan denied your request. The Plan says this claim was filed untimely.  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 the hearing aids was not filed until August 13, 2021. 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 the behind the ear hearing aid, digital, monaural (V5257) provided November 20, 2018.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on June 16, 2021.  

You asked the Plan to pay for lab tests. You say that at this time there is no contractual agreement in place which indicates that the codes billed are included in the dialysis rate. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is included in the end-stage renal disease (ESRD) prospective payment system (PPS) and is not paid separately.  

The Plan must follow Medicare rules. Medicare rules say that lab services furnished to individuals for the treatment of end-stage renal disease (ESRD) are included in the ESRD prospective payment system (PPS) and are not paid separately.   

We looked at the file and Medicare rules. These lab services are included in the ESRD PPS rate paid to the dialysis facility and are not separately payable. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the consultation (D9310) provided on July 14, 2021.  You asked the Plan to pay for the consultation. You say that you were told this service would be covered, and you would like it covered under either your medical or dental benefits. The Plan denied your request. The Plan says this service is not covered.  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 consultation (D9310) provided on July 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 4, 2021, to June 2, 2021.  You asked the Plan to pay for the SNF care provided from May 4, 2021, to May 8, 2021, and May 10, 2021, to June 2, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive skilled care on the dates of service in this case.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care provided from May 4, 2021, to May 8, 2021, and May 10, 2021, to June 2, 2021. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  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 SNF care provided from May 4, 2021, to May 8, 2021, and May 10, 2021, to June 2, 2021. have not been met. Specifically, the file shows that the enrollee did not receive skilled care on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 4, 2021, to June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dentures (D5110 and D5120), provided on August 8, 2021.  

You asked the Plan to pay for the dentures. You say that you thought the items would be covered. The Plan denied your request. The Plan says these are not covered items.  

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. Specifically, the items received are not listed in the Plan's benefit chart. This means they are not covered. Therefore, we decided that the Plan does not have to pay for the dentures (D5110 and D5120), provided on August 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on August 11, 2021.  

You asked the Plan to pay for the services provided. You say that there is no agreement that the billed codes are included in the dialysis rate. The Plan denied your request. The Plan says the test is not separately reportable.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.   

We looked at the file and the rules. The file shows that parathyroid hormone testing was provided. The records show that the services were related to the enrollee's ESRD.  

Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional accessories (E2311, K0108) for a power wheelchair.  

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says upper extremity strength and function are adequate to control the power options using their own switch which are included in the allowance of these power options.  

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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records document that the enrollee has 3+/5 upper extremity strength and is independent with feeding thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. The shroud is not covered as it does not serve a medical purpose.  

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories (E2311, K0108) for a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging provided on May 27, 2021.  You asked the Plan to waive the copayment for ophthalmic diagnostic imaging. You say that you disagree with the charges because you have never been charged for this service in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for diagnostic procedures and tests.   You have been asked to pay the allowed amount of $40.96, which is less than the $65 copayment for ophthalmic diagnostic imaging. Ophthalmic diagnostic imaging 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 ophthalmic diagnostic imaging provided on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function 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.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records document that the enrollee has 3+/5 to 4/5 upper extremity strength and is independent with equipment with upper extremity bathing and upper extremity dressing thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.