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) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's 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 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 3 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 upper extremities with the ability to feed himself indicates that the enrollee can control any power options through their own individual 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) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear medicine services provided on May 17, 2021.
You asked the Plan to waive the copayment for nuclear medicine services. You say that a representative of the Plan told you to disregard this bill. The Plan denied your request. The Plan says the correct 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 $495 copayment for nuclear medicine services at an outpatient hospital. You have been asked to pay a $495 copayment for nuclear medicine services. Nuclear medicine services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for nuclear medicine services provided on May 17, 2021.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility from a representative of the Plan 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and
above those usually included in an office visit or other non-facility service(s), when performed during a Public
Health Emergency as defined by law, due to respiratory-transmitted infectious disease (99072) provided from
March 1, 2021, through April 5, 2021.

You asked the Plan to pay for additional supplies, materials, and clinical staff time. The Plan denied your
request. The Plan says there are no clinical records to support the medical necessity.

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
additional supplies, materials, and clinical staff time has a bundled relationship with code 99072 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 additional supplies,
materials, and clinical staff time over and above those usually included in an office visit or other non-facility
service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted
infectious disease (99072) provided from March 1, 2021, through April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on May 15, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the service was provided with no adequate time frame to obtain authorization. The enclosed medical records clearly reflect the medical necessity for the services rendered. 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 subsequent nursing facility care (99309) provided on May 15, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the LifeVest device you rented on May 28, 2021.
You asked the Plan to waive the coinsurance for the LifeVest. You say that you had this vest for two weeks and then returned it, so you thought you would not be responsible for any cost sharing. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment benefit category. This cost sharing applies even if you return the item. 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 the LifeVest device you rented on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan has to pay for to pay for the acute inpatient hospital care provided to the enrollee on
January 29, 2021 billed under code 22325.

You asked the Plan to pay for inpatient care provided to the enrollee. You say that this claim should be paid.
The Plan denied your request. The Plan says that the records provided do not support the claim billed.
The Independent Contractor (QIC) originally upheld the Plans decision. However, after a question for clarification was posed to our Medical Director, Independent Contractor (QIC) reopened the case.

Our Medical director looked at the case file and the original decision. At issue is coverage for services coded as
22325 which is defined as open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s),
posterior approach, one fractured vertebra or dislocated segment; lumbar and inpatient admission. While the
enrollee did not have a vertebral fracture, the documentation supports that there was severe spinal stenosis
resulting from severe ligamentous hypertrophy together with facet hypertrophy and the spondylosis itself.
Therefore, procedural code 22325 is supported by the documentation in the case file.

We looked at the Medical Director's review, the file, and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of code 22325 with inpatient admission are met. Therefore, we
decided that the Plan has to pay for to pay for the acute inpatient hospital care provided to the enrollee on
January 29, 2021 billed under code 22325.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from November 19,
2020, through December 11, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you should be reimbursed for some of
the $391 for the non-covered prescription charges. The Plan denied your request. The Plan says Medicare Part
B does not cover self-administered drugs.
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 pay for the self-administered drugs
provided from November 19, 2020, through December 11, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for repositioning of intraocular lens prosthesis, requiring an incision (separate procedure) (CPT code 66825-59) provided to the enrollee on March 16, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this service is not covered as billed.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

CPT code 66825 has a designation of "separate procedure" per CPT. According to the operative report the service was performed in the same anatomical area, through the same incision. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for repositioning of intraocular lens prosthesis, requiring an incision (separate procedure) (CPT code 66825-59) provided to the enrollee on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311) for the enrollee.
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 additional accessories. Our reviewer says that the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2300 is not primarily medical in nature and therefore not medically necessary. The E2311 is not medically necessary, as the documentation does not reveal that the enrollee requires other type 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 in the upper extremities supports that the enrollee can control any power options through their own individual switches. Also, as the E2300 is not medically necessary, the E2311 is not needed to control the E2300. 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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ophthalmology visit and the
ophthalmic biometry test you had on May 10, 2021.
You asked the Plan to waive the copayments for the ophthalmology visit and the ophthalmic biometry test. You
say that you should not have to pay these copayments because this doctor refused to remove your cataract
without removing the existing scar tissue. The Plan denied your request. The Plan says you were charged these
copayments 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 tests and a $35 copayment for specialist visits.
You have been asked to pay a $35 copayment for the ophthalmology visit and a $10 copayment for the
ophthalmic biometry test. The ophthalmology visit falls in the specialist visit benefit category and the
ophthalmic biometry test falls within the diagnostic tests benefit category. These copayments apply regardless
of your satisfaction with the provider. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the ophthalmology
visit and the ophthalmic biometry test you had on May 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy provided on April 30, 2021.

You asked the Plan to pay for the electrical stimulation therapy. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.

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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended).

We find that CPT code 97014 is not supported in the medical record. Specifically, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is considered invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the electrical stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine and a tetanus vaccine provided on April 29, 2021.
You asked the Plan to pay for a shingles vaccine and a tetanus vaccine. You say that you were told you needed these vaccines and did not know they were not covered. The Plan denied your request. The Plan says coverage of these vaccines is the responsibility of your prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and a tetanus vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and a tetanus vaccine. Therefore, we decided that the Plan does not have to pay for a shingles vaccine and a tetanus vaccine provided on April 29, 2021.
Benefits for a shingles vaccine and a tetanus vaccine 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a privacy flap (K0108).

You asked the Plan to pre-approve a privacy flap. You say that the enrollee needs this item. The Plan denied your request. The Plan says this item does not serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a privacy flap (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic pathogen testing provided on August 11, 2020, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798.
You asked the Plan to pay for the genetic testing as billed. You say that this is medically necessary testing which should be paid. The Plan denied your request. The Plan says these tests were reported with the incorrect POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate that this sample was taken directly by the laboratory. As such, the reported POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the genetic testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic pathogen testing provided on August 11, 2020, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic images (D0350), oral hygiene instructions (D1330), and resin-based composites (D2331) provided on May 5, 2021.

You asked the Plan to pay for the 2D oral/facial photographic images, oral hygiene instructions, and resin-based composites. You say that you went in for a cleaning and have never heard of having a cleaning without x-rays. You also say that you were not advised that you needed to see an in-network provider. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 2D oral/facial photographic images (D0350), oral hygiene instructions (D1330), and resin-based composites (D2331) provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 10, 2019, to December 11, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like these services reprocessed based on medical necessity. The Plan denied your request. The Plan says observation level of care would have been more appropriate.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then 68-year-old male who presented to the emergency department on December 10, 2019, with a history of 2 days of chest and wrist pain. The evaluation revealed a normal physical exam; electrocardiogram was normal sinus rhythm with premature ventricular contractions. Cardiac biomarkers were normal. He was admitted to telemetry; underwent a stress echo on December 11, 2019, and was discharged home with outpatient follow-up. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided December 10, 2019, to December 11, 2019.