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

 We decided that the Plan does not have to pre-approve attendant control for a power wheelchair (PWC).  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that attendant control is covered when specific criteria are met.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has neurogenic bladder, sleep apnea, lumbar pain, spinal cord injury with quadriplegia and diplegia, constipation, depression, and is continuous positive airway pressure (CPAP)-dependent. The documentation does not reveal that he is unable to operate his power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair. The attendant control is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve attendant control for a power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the observation care services provided on August 27, 2021.  You asked the Plan to pay for the services provided. You say that the services rendered were of medical necessity. The Plan denied your request. The Plan says the code can only happen once for the date of service.  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 the rules. The records show that the initial observation care code was previously billed and paid for by the plan. Physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. 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 observation care services provided on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ophthalmological services provided on May 25, 2021.  You asked the Plan to waive the copayment for ophthalmological services. The Plan denied your request. The Plan says the Evidence of Coverage (EOC) indicates the member's coinsurance for a vision exam is $35.  Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan processed the claim with the correct copayment. Therefore, we decided that the Plan does not have to waive the copayment for ophthalmological services provided on May 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 15, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says when an ambulance service is provided but it does not involve a transport, it is not a covered service and is a beneficiary liability.  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 July 15, 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 (A0998) provided on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for foot orthotics on July 22, 2021.  You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional laboratory services (procedure code 86078) provided to the enrollee on June 15, 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 no additional documentation supporting additional services which were billed and remain denied.  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 86078 is "Blood bank physician services; investigation of transfusion reaction including suspicion of transmissible disease, interpretation and written report."  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical records provided does not include sufficient documentation to validate billing an additional unit of 86078, therefore, no additional payment is allowed.  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 additional laboratory services (procedure code 86078) provided to the enrollee on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on March 5, 2020.  You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you have Medicaid and should not owe anything. 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 20% coinsurance for Medicare Part B prescription drugs.   You received Medicare Part B drugs on March 5, 2020. The record shows at the time services were received you were not covered under Medicaid. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $152.49 and 20% of that is $30.49.   You have been asked to pay the total coinsurance amount of $30.49 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient services provided from  December 29, 2019, through January 5, 2020.  You asked the Plan to waive the copayment for the inpatient services. You say that the claim processed incorrectly because the actual admission date was December 30, 2019, and the cost-share applied was not valid. The Plan denied your request. The Plan says the claim processed correctly per the Evidence of Coverage.  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 In-Network Days 1-7: $225 copayment per day (per Medicare-covered hospital stay) which includes day of admission and day of discharge. After the 7th day, the plan pays 100% of covered expenses.  You have been asked to pay In-Network Days 1-7: $225 copayment per day (per Medicare-covered hospital stay) which includes day of admission and day of discharge. However only $420.58 applied to claim as your out of pocket was met with processing of this claim. The inpatient services falls within the Inpatient Hospital Care 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 inpatient services provided from December 29, 2019, through January 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on September 2, 2021, and September 3, 2021.  You asked the Plan to pay for the self-administered drugs. You say that the enrollee went to the hospital for a knee replacement and was not allowed to bring in her own medications to the hospital with her to take herself. You also say that you feel since the enrollee was not allowed to take in the medically necessary medication with her that the insurance should cover it in full, with no member responsibility. The Plan denied your request. The Plan says self-administered drugs that are covered under Part D that are administered in an outpatient setting are not covered under the medical coverage.  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 on September 2, 2021, and September 3, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CT scan provided on May 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the CT scan. You say that the enrollee has established care and wishes to continue seeking services for their condition under this physician at the out-of-network location. You say you have requested in-network participation. 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 a computed tomography (CT) scan provided on May 6, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer for the enrollee.  You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of instability, no remarkable scoliosis, or severe osteoporosis.  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 spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process spacer devices are experimental. More research is needed to show safety and efficacy of the devices.  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 spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on November 3, 2020.  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 billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) provided on September 3, 2021.  You asked the Plan to pay for the office visit. You say that you were not aware you would be charged for this service. The Plan denied your request. The Plan says these services are not covered when performed by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202) provided on September 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 23, 2021.  You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on February 17, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an impression and custom preparation of an oral surgical splint (21085) and cast supplies (A4580) provided from August 4 to August 18, 2021.  You asked the Plan to pay for an impression and custom preparation of an oral surgical splint and cast supplies. You say that you had a lot of pain for about 6 months and decided to pay for the treatment at issue as you felt you did not have options. The Plan denied your request. The Plan says rules for payment have not been met because the treatment at issue is not a covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Medicare rules also say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an impression and custom preparation of an oral surgical splint have not been met. Specifically, the case record does not contain documentation to support the medical necessity of an impression and custom preparation of an oral surgical splint. Additionally, code A4580 has a status indicator of "I" on the Physician Fee Schedule. This means that it is "invalid for Medicare billing purposes." Based on this information, we decided that Medicare rules for coverage of code A4580, cast supplies, have not been met. Therefore, we decided that the Plan does not have to pay for an impression and custom preparation of an oral surgical splint (21085) and cast supplies (A4580) provided from August 4 to August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided February 18, 2021.  You asked the Plan to pay for the outpatient hospital services. You say that the records provided support the necessity of the service in dispute. The Plan denied your request. The Plan says services not rendered, paid per PPS/Billed charges.   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 enrollee received the services during preparation for a procedure or surgery at the facility. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the procedure or surgery. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided February 18, 2021.
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 19, 2021.  You asked the Plan to pay for the bitewing x-rays. You say that as stated in your dental benefits you can get one x-ray per year, and you see nothing online or in your materials that states only a specific type of x-ray is covered. You also say that you do not understand why the insurance company would want you to receive a full mouth or panoramic x-ray every year as opposed to bitewing x-rays. The Plan denied your request. The Plan says this service is not covered by the Plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9348) provided from July 16, 2021, through July 21, 2021.  You asked the Plan to pay for home infusion therapy. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this code is not eligible for payment based on 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, code S9348 has a Status Indicator of "I" under the Physician Fee Schedule indicating that it is not valid for Medicare purposes. Specifically, Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9348) provided from July 16, 2021, through July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and wrist/hand orthoses provided to the enrollee on April 5, 2021.  You asked the Plan to pay for the orthoses. You say that these items were medically necessary. The Plan denied your request. The Plan says that the documentation submitted did not include an itemized shipping/billing invoice to indicate specific supplies, or proof of delivery.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthoses and wrist/hand orthoses provided to the enrollee on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110) provided on December 11, 2020.  You asked the Plan to pay for physical therapy services. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that the rules state that the services of Physical Therapy Assistants (PTAs) used when providing covered therapy benefits are included as part of the covered service. These services are billed by the supervising physical therapist. A physical therapist must supervise PTAs.   We looked at the file and Medicare rules. The services at issue were provided by a PTA but were not billed by a supervising physical therapist. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97110) provided on December 11, 2020.