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

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).  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 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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require 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 documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). The enrollee's strength and functional ability should be sufficient to control any power options through 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on July 30, 2021.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this should have been reported with CPT 81479.  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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for mastectomy prosthetics provided on October 8, 2021.  

You asked the Plan to waive the coinsurance for the mastectomy prosthetics. You say that the provider advised you that there would not be a copayment. The Plan denied your request. The Plan says the correct coinsurance was applied.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each durable medical equipment (DME) item.  

Item Allowed Amount 20% Coinsurance 
Mastectomy Bra (L8000) $263.88 $52.78 
Mastectomy Form (L8020) $227.98 $45.60 
Breast Prosthesis w/o Adhesive (L8030) $329.76 $65.95 
Total:  $164.33 

You have been asked to pay $164.33, which is 20% of the allowed amount for the mastectomy prosthetics. The mastectomy prosthetics fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for mastectomy prosthetics provided on October 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan
denied your request. The Plan says an IRF admission is not medically necessary.
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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that based on the medical records provided, the complexity of your nursing, medical
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care.
Your medical conditions are stable on outpatient medications with no issues that require a physician's
evaluation three or more times per week. You do require physical therapy and occupational therapy services
but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy
program. There is no documentation that you require the intensive rehabilitation therapy program provided in
an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this
case.
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 28, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  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 laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for outpatient hospital services
provided on July 20, 2021.
You asked the Plan to waive the deductible and copayment for the outpatient hospital services. You say that the
Plan should pay for the services, and it should not be your responsibility. The Plan denied your request. The
Plan says the proper deductible and copayment was applied for the service.
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 $750
deductible and once you have paid your deductible, we will begin to pay our share of the costs for covered
medical services and you will pay your copayment or coinsurance amount for the rest of the calendar year.
Prior to the date of service your total deductible paid was $731.91 towards the $750 total deductible amount.
For the service provided you were charged $18.10 which brought your total deductible amount to $750
($731.91 prior deductible + $18.10 deductible charged).
Your contract with the Plan also clearly says that you must pay a $350 copayment for Medicare-covered
surgery or other services provided to you at an outpatient hospital. The total amount allowed after the
deductible was subtracted was $258.13 ($276.23 total amount - $18.10 deductible). The $258.13 charged is less
than the copayment amount of $350. Therefore, $258.13 was charged as the copayment amount.
You have been asked to pay a $18.10 deductible and a $258.13 copayment for outpatient hospital services. The
deductible amount falls within the Outpatient Surgery and Other Medical 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 deductible and copayment for outpatient hospital services provided on July 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on July 19,
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 there is a more appropriate code to use in this case.

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 97530 is "Therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes."

We find that CPT code 97530 is not supported in the medical record. Specifically, it is inappropriate for a nurse
practitioner to be billing these services. Based on this information, we decided that Medicare rules for coverage
of the services have not been met. Therefore, we decided that the Plan does not have to pay for physical
therapy services provided to the enrollee on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device
provided on July 19, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the CPAP device. You say that the in-network supplier would not give you the
CPAP device. The Plan denied your request. The Plan says there is a list of in-network suppliers that would
meet the enrollee's need for the device. Without prior authorization to use an out-of-network supplier the
request would be denied.
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 a continuous positive airway pressure (CPAP)
device provided on July 19, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0425, A0428) provided on September 8, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not know these services would cost this much. The Plan denied your request. The Plan says these services are covered, 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 $200 copayment for each one-way ambulance trip.   You have been asked to pay a $200 copayment for the ambulance transportation. 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 (A0425, A0428) provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a tooth extraction
(D7140) provided by an out-of-network provider on August 17, 2021.

You asked the Plan to pay for a limited oral evaluation and a tooth extraction. You say that you needed an
emergency tooth extraction. The Plan denied your request. The Plan says D0140 and D7140 are not covered
dental benefits.

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 a limited
oral evaluation (D0140), and a tooth extraction (D7140) provided by an out-of-network provider on August 17,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services rendered on July 29, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that investigational services related to clinical trials must
be billed with the Q0 or Q1 modifier.
We looked at the file and Medicare rules. The file shows that billed procedure code 88305 (surgical pathology)
was performed as part of a clinical trial and was not billed with the required Q0/Q1 modifier. Therefore, we
decided that the Plan does not have to pay for the pathology services rendered on July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (coded K0861) along with multiple accessories.

You asked the Plan to pre-approve the Group 3 wheelchair with multiple power options. You say that the requested wheelchair should be covered as it is required for the enrollee's daily living activities. The Plan denied your request. The Plan says the criteria for the specific power wheelchair base requested have not been met.

The Plan must follow Medicare rules. Medicare rules say that coverage for Group 3 power wheelchairs with multiple power options is only allowed when the criteria for a power tilt and recline seating system are met, or the enrollee uses a mounted ventilator. 

In this case, the base code requested cannot be covered as only a power tilt seating system is requested, with no power recline. There is no evidence of the need to mount a ventilator on the wheelchair. As such, the criteria for this wheelchair base have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (coded K0861) along with multiple accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431).
You asked the Plan to pre-approve a portable gaseous oxygen system. You say that the requested item is a
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the
requested item have not been met.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.
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 a portable gaseous oxygen system. Our
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician
reviewer found that there are no oxygenation measurements that meet Medicare criteria for oxygen
need. Recent vital signs show adequate oxygenation at rest breathing room air. There is no information on
oxygenation during exertion or sleep.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a portable gaseous oxygen system have not been met. Therefore, we decided
that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary as you do
not have the support you need to recover. The Plan denied your request. The Plan says the information that the
Plan received does not show that you had completed your full course of care in the inpatient rehabilitation
facility (IRF). Your request does not meet Medicare guidelines because you were receiving adequate and
necessary intensive rehabilitation in the IRF.
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 pre-approve SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found based on the medical records
provided there is no documentation that you required skilled nursing services as of October 26, 2021. You were
on outpatient medications with no feeding tube or complex wounds. You did require skilled therapy services,
but the acute inpatient rehabilitation facility was able to provide for all of your therapy needs and the health
Plan has stated that continued care in the acute inpatient rehabilitation facility would have been covered. Daily
skilled therapy services were required. As a practical matter, you do not require the services on an inpatient
basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation facility was
appropriate until you were stable to transfer to a lower level of care such as at home with home health 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 15, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for psychotherapy
services have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's
attending or primary care physician.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services
provided from March 2, 2021, to March 31, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that the stay was related to the
enrollee's coronavirus diagnosis and should have no copayment. The Plan denied your request. The Plan says
the enrollee has been charged 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). The enrollee's contract with the Plan clearly says that enrollees
must pay $0 per day for days 1-20 and $160 per day for days 21-100 for each skilled nursing benefit period.

The file shows that the enrollee was under skilled nursing care from March 2, 2021, to March 31, 2021. There
is no copayment for the first 20 days (March 2, 2021, to March 21, 2021). The enrollee has been asked to pay
$160 per day for days 21-30 for the SNF services. The total for the SNF stay is $1600 ($160 copayment x 10
days = $1600). Please note that there is no copayment on the discharge date. The SNF services fall within the
Skilled Nursing Facility (SNF) Care benefit category. The file also indicates that the provider verified with the
Plan that the stay was not related to the enrollee's coronavirus diagnosis. This means that the enrollee has been
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for skilled nursing facility (SNF) services provided from March 2, 2021, to
March 31, 2021.

Your complaint about the Plan customer service representatives misinforming you of the charges along with
the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient services provided by on July 19, 2021.  You asked the Plan to waive the copayment for the outpatient services. You say that you never received surgery and the copayment should be a different amount. The Plan denied your request. The Plan says the provider billed for this service and the proper copayment was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center.     You have been asked to pay a $395 copayment for the outpatient services. The outpatient services falls within the Outpatient Surgery and Other Medical 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 copayment for outpatient services provided by on July 19, 2021.