Persius/hicric huggingface dataset:
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 total electric hospital bed. You say that you have a history of falling and are concerned when entering or exiting the bed. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered by Medicare. We looked at the file and Medicare rules. The requested total electric hospital bed is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between two systems identified with code E2311, the expandable controller identified with code E2377, and the expandable controller harness identified with code E2313.
You asked the Plan to pre-approve electronic connection between two systems, the expandable controller, and the expandable controller harness. 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 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 electronic connection between two systems, the expandable controller, and the expandable controller harness. 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 three 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 left upper extremity with the ability to be independent in grooming, upper body dressing, toileting supports that the patient can control any power options through their own individual switches. Therefore, the enrollee does not meet criteria for the requested wheelchair accessories. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electronic connection between two systems, the expandable controller, and the expandable controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection between two systems identified with code E2311, the expandable controller identified with code E2377, and the expandable controller harness identified with code E2313.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on March 5, 2021.
You asked the Plan to pay for the services provided. You say that the physician provided services in good faith. The Plan denied your request. The Plan says no other payment is allowed.
The Plan must follow Medicare rules. Medicare rules say that that claims or claim lines that have been determined to be exact duplicates of another claim are denied.
We looked at the file and the rules. We find that the services at issue were billed and paid for by the Plan under a separate claim. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on April 28, 2021.
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that this cost seems very high for the shot you received. 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 $250 copayment for each outpatient hospital service, including observation, surgery, or procedures.
You have been asked to pay a $250 copayment for the arthrocentesis procedure. The arthrocentesis procedure falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 29, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit (99214). You say that you were unable to get an authorization before the service was provided. The Plan denied your request. The Plan says the services were not urgent, emergent nor approved in advance.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 29, 2021 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work, the electrocardiogram, and the office visit provided on May 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work, the electrocardiogram, and the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work, the electrocardiogram, and the office visit provided on May 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for wound care provided on May 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit for wound care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the home visit for wound care provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound strapping procedure you had at a hospital-owned wound clinic on April 30, 2021.
You asked the Plan to waive the copayment for the wound strapping procedure. You say that you were seen at a wound center, but it is being billed as a hospital. You say that you were in there less than fifteen minutes and you brought your own medications. You said all they did was change the bandage, so you don't feel as though it is correct for them to charge a surgery copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that since the allowed amount for the wound debridement procedure ($278.17) is less than your copayment obligation, you are responsible for the full allowed 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 $400
copayment per visit for outpatient surgery, including services provided at hospital outpatient facilities. You have been asked to pay a $400 copayment for the wound strapping procedure. Wound strapping is considered a surgical service. Because the facility where you received this service is considered an outpatient hospital facility, the wound strapping procedure falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the wound strapping procedure you had at a hospital-owned wound clinic on April 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on
February 24, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you collapsed on
the bathroom floor and your wife called 911 as you were unresponsive. You say that before the paramedics
arrived you felt better. You say the paramedics took your vitals and found everything to be normal, so you
refused to go to the hospital as this has happened to you before. The Plan denied your request. The Plan says
the service in question is not covered under the member's contract under any normal circumstances.
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 February 24, 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 ambulance response and treatment, no transport
provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care, per day, for the evaluation and
management of a patient (99220) provided on May 11, 2021, by an OON provider.
You asked the Plan to pay for the initial observation care. You say that the hospital should have obtained
authorization for the services. The Plan denied your request. The Plan says the services were provided OON,
and the enrollee was not referred by a network provider; therefore, the services are not covered.
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 initial observation care, per day, for the
evaluation and management of a patient (99220) provided on May 11, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) and polycarbonate lenses (V2784) provided on June 18, 2021.
You asked the Plan to pay for progressive lenses and polycarbonate lenses. You say that you did not use any of your vision benefits last year due to Covid-19. you also say that this is the first time you use your vision benefit this year and would like the claim reviewed. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.
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 contract says that you receive a $250 allowance for supplemental eyewear every year. Members are responsible for all costs over and above the allowance amount. We looked at the file and the Plan's rules. The records show you exhausted your $250 maximum allowed benefit on June 18, 2021. The records also show that the total cost of your eyewear was $359. The Plan paid the maximum allowed amount of $250, leaving a balance of $109, in which you are responsible for. The EOC confirms that members are responsible for all costs over the allowance amount. Based on this information, we decided that the Plan's rules for coverage of progressive lenses and polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) and polycarbonate lenses (V2784) provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), intraoral X-rays (D0210), and dental cleaning (D1110) provided on May 26, 2021.
You asked the Plan to pre-approve a comprehensive oral evaluation, intraoral X-rays, and dental cleaning. You say that you do not understand how the calendar-year maximum could have been met since the date of service at issue was the first time you had been to the dentist in two years. The Plan denied your request. The Plan says rules for payment have not been met because the annual dental allowance for 2021 has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides a $1000 dental allowance to reimburse selected supplemental preventive and comprehensive dental services. You are responsible for any amount over and above the allowance amount.
We looked at the case file, the Plan contract, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, intraoral X-rays, and dental cleaning have not been met. The Plan has documented that the $1000 annual dental allowance has already been applied in its entirety to services received on June 2, 2021. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), intraoral X-rays (D0210), and dental cleaning (D1110) provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic resonance angiography (MRA) represented by code 70544 provided on March 4, 2021.
You asked the Plan to pay for code 70544. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 has a bundled relationship with code 70551 and cannot be paid as billed. 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 the Magnetic resonance angiography (MRA) represented by code 70544 provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exams provided on May 10, 2021, by an OON
provider.
You asked the Plan to pay for the tissue exams. You say that the services were medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the tissue exams provided on May 10, 2021, by an OON
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on
June 15, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee out of
network on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (15570) provided on February 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 15570 is "Formation of direct or tubed pedicle, with or without transfer; trunk". 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 use of code 15570 is not supported by the records provided. Our reviewer found that the operative report does not include enough
detail to confirm this procedure has been performed. Per the operative report, "The inferiorly-based skin flap
was then de-epithelialized and developed as a flap, having a width of roughly 25 cm and a height of roughly 14
cm. The flap was undermined slightly medically and laterally to fully develop it". The operative report does not
describe the reconstructive technique in which the skin and soft tissue to be used for the flap is formed into a
tubular pedicle, and moved from the source to the target site by anchoring at both ends, periodically severing
one end and anchoring it closer to the flap target.
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 the services (15570) provided on February 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examination (88305) provided on May 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that your services were medically necessary in providing a medical diagnosis for the enrollee's referring physician. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 surgical pathology, gross and microscopic examination (88305) provided on May 13, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided on December 8, 2020.
You asked the Plan to pay for surgical assistant services. You say that the Plan's denial does not meet any
industry standards or norms for this type of service and network status. The Plan denied your request. The Plan
says the denial of payment for these services is correct, because the primary surgeon has not billed this code for
this date of service.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided
on December 8, 2020