Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided by a network facility on July 28, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that this service was rendered as a result of anesthesia and pain medicine provided during surgery. You say since the surgery was 100% covered, then the x-ray should also be 100% covered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each in-network Medicare-covered standard x-ray service.
You have been asked to pay a $15 copayment for the x-ray. The x-ray falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the x-ray was considered a separate service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the x-ray provided by a network facility on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311).
You asked the Plan to pre-approve an electronic connection. You say that this is medically necessary. The Plan denied your request. The Plan says that because you are able to the control power tilt with its own switch, there is no need to control the power option through the joystick.
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 an electronic connection. Our reviewer says that an electronic connection is not considered medically reasonable and necessary in this case. Your wrists and hands are "within functional limits" and you have 3 out of 5 upper extremity strength and you are independent with eating thus indicating you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.
Our physician reviewer found that your condition does not meet criteria for an electronic connection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on October 15, 2021.
You asked the Plan to pay for the CGM supplies. You say that the item is medically necessary. The Plan denied your request. The Plan says the order is not signed by the treating provider.
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 physician order. The order is not signed by the treating physician. 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 continuous glucose monitor (CGM) supplies (K0553), provided on October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from July 2, 2021, to July 9, 2021.
You asked the Plan to pay for IRF care. You say that these services were medically necessary. The Plan denied your request. The Plan says there is no clinical documentation to support the medical necessity of these services.
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 pay for IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Medical records were submitted after the Plan's denial and were forwarded for review. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for chest pain. Medical problems were stable; there were no complex nursing or rehabilitation needs. The enrollee did not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee had a need for physical and/or occupational therapy, there was no documentation of a need for an intensive rehabilitation program. At the time of admission, there was not a reasonable expectation that this enrollee would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF, and the necessary care could have been provided in a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from July 2, 2021, to July 9, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for surgical services (procedure code 22800) provided to the enrollee on July 14, 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 that the records do not support the services 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, the CPT Code Manual definition of code 22800 is "Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments." 

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 supported by the medical records. Our reviewer found the operative report does show bone fusion at six levels. The graft was placed at these levels posterior. The code is supported and should be approved. 

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 been met. Therefore, we decided that the Plan has to pay for surgical services (procedure code 22800) provided to the enrollee on July 14, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bumetanide, 0.5mg tablets.
You asked the Plan to pre-approve Bumetanide, 0.5mg tablets. You say that this medication is necessary based on treatment failure with the medication Lasix, which did not show adequate therapeutic response. The Plan denied your request. The Plan says Bumetanide tablets are not covered under the Part A or B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Bumetanide, 0.5mg tablets.
Benefits for Bumetanide, 0.5mg tablets 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 waive the copayment for the prostate specific antigen (PSA) test you received on November 26, 2021.
You asked the Plan to waive the copayment for the PSA test. You say that you are entitled to one free PSA test per year. 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 $10 copayment for diagnostic lab tests. You have been asked to pay a $10 copayment for the PSA test. Your contract says there is no cost sharing for an annual screening PSA test. However, if you are also treated or monitored for an existing medical condition when you receive this service, cost sharing may apply. We looked at the records in this case. For the PSA test you received, it shows that this was performed to monitor your known condition of prostate cancer. It was not ordered as a screening test. Your contract says that only screening PSA tests have no cost sharing.
Your contract says that for non-screening PSA tests, the diagnostic lab cost share will apply. 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 prostate specific antigen (PSA) test you received on November 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the vertical bitewings (D0277) and prophylaxis (D1110) provided on September 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the vertical bitewings and prophylaxis. You say that you were billed the difference in the amount of $231 because the provider is OON. You also say that in the enrollment manual, there is no difference in copay for in-network or OON. The Plan denied your request. The Plan says the total $120 amount for these services applied correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the vertical bitewings (D0277) and prophylaxis (D1110) provided on September 22, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transcutaneous nerve stimulation (tens) unit.
You asked the Plan to pre-approve the TENS unit. You say that you are appealing the denial of referral for a DME TENS unit. The Plan denied your request. The Plan says the Medicare criteria has not been met for the requested TENS unit.
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 TENS unit. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not enrolled in a clinical trial and therefore, the request is considered not medically reasonable or 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 the TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve the transcutaneous nerve stimulation (tens) unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the bathroom safety equipment provided on September 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the bathroom safety equipment. You say that you did not know you needed to purchase this equipment from a contracting supplier. The Plan denied your request. The Plan says these items must be purchased through a contrated provider.

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 bathroom safety equipment provided on September 10, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), deep cleanings (D4341 x 4), gingival irrigation (D4921 x 4), and take home drugs (D9630 x 3) provided on October 14, 2021.
You asked the Plan to pay for the adjunctive pre-diagnostic test, deep cleaning, gingival irrigation, and take home drugs. You say that the provider did not advise why these services needed to be done. You say that you paid $1,700 cash for these services. You also say that you feel you should not have been charged $1,700. The
Plan denied your request. The Plan says the adjunctive pre-diagnostic test, deep cleaning, gingival irrigation, and take home drugs are not listed as covered services.
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 adjunctive pre-diagnostic test, deep cleaning, gingival irrigation, and take home drugs are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), deep cleanings (D4341 x 4), gingival irrigation (D4921 x 4), and take home drugs (D9630 x 3) provided on October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic surgical services provided to the enrollee on June 7, 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 the requested service code is not substantiated by the clinical documentation.
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 24516 is a column II code to column I code 24435. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for orthopedic surgical services provided to the enrollee on June 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided by a network facility from April 30, 2021, to May 14, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you were at the same facility and were moved to their rehabilitation facility. You say you should not have a second copayment.
The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for each day for days 1 to 7 per admission and a $0 copayment each day for days 8 to 90 per admission.
You have been asked to pay a $1,225 copayment for the inpatient rehabilitation stay. ($175 x 7 days = $1,225). The inpatient rehabilitation stay falls within the "Inpatient Hospital Care" benefit category. The record shows the inpatient rehabilitation stay is considered a separate service from the inpatient acute stay. 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 inpatient rehabilitation stay provided by a network facility from April 30, 2021, to May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the copayment for remote cardiac monitoring provided on February 2, 2021.
You asked the Plan to waive the copayment for remote cardiac monitoring. You say that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says that you have 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. Your contract with the Plan says that enrollees must pay a $0 copayment for diagnostic tests and procedures. The Plan says you must pay a $35.18 copayment for remote cardiac monitoring. Remote cardiac monitoring falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for remote cardiac monitoring. Therefore, we decided that the Plan has to waive the copayment for remote cardiac monitoring provided on February 2, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a contracted provider on October 18, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that you went back because you had a pain in your mouth. The Plan denied your request. The Plan says the benefit limit for a limited oral evaluation has already 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 covers one limited oral evaluation per calendar year.
We looked at the file and Medicare rules. Evidence was provided to show that D0140 was provided on October 12, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a contracted provider on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal
implants (D6010).
You asked the Plan to pre-approve the endosteal implants. You say that you would like to appeal these services. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve surgical placements of implant bodies: endosteal implants (D6010).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee.
You asked the Plan to pre-approve the pacemaker. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that the procedure is part of a Food and Drug Administration approved Coverage with Evidence Development (CED) study.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are covered by Medicare through Coverage with Evidence Development (CED). There is no evidence that this request is being made through an approved CED study. Based on this information, we decided that Medicare rules for coverage of the pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64483 provided on April 16, 2021.
You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has denied correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64483 provided on April 16, 2021.