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

We decided that the Plan does not have to pre-approve a Tuffcare three-wheeled walker for the enrollee.
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee was previously provided with a four-wheeled walker and recently a quad,
and these items meet the enrollee's daily need inside the home.
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 walker. Our reviewer says that the
requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided, there is no detailed documentation from the prescribing provider
that the enrollee has a mobility limitation that impairs ability to participate in mobility-related activities of daily
living. There is no detailed statement from the provider asserting that the enrollee would be able to safely use
this walker. There is no evidence that the enrollee's functional deficit would be sufficiently with this walker
over the items that have already been provided.
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 walker have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Tuffcare three-wheeled walker for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 lab work provided on December 1, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 66-year-old female with a history of hypertension, Crohn's breast cancer and other medical condition. Based on the documentation provided, you do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. Your medical conditions are chronic. There is no evidence of new injury or illness. Your functional status appears to be her baseline following a femur fracture and multiple rounds of rehabilitation. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs are custodial and, as a practical matter, can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a labial veneer (D2962), provided on April 20, 2021.
You asked the Plan to pay for the routine dental service. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is not covered under your supplemental benefit.
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. Specifically, the requested service is not listed in the Plan's supplemental dental benefit chart. This means the service is not covered by the Plan. Therefore, we decided that the Plan does not have to pay for a labial veneer (D2962), provided on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation.
You asked the Plan to pre-approve multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records did not show that the enrollee had failed conservative treatments such as leg raising, compression stockings, weight loss, etc. to help justify this procedure. Therefore, this request for such will be considered not medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services (A0429) 
provided on January 4, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not call 
for the ambulance so you should not be responsible for this charge. The Plan denied your request. 
The Plan says this processed 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 $210 copayment for each one-way Medicare-covered ground ambulance 
service.  
 
You have been asked to pay a $210 copayment for ambulance services. 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 ambulance services 
(A0429) provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on March 29, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided on May 7, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (G0482) provided on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee needs supportive seating to enable
safe and effective bathing. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 10, 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 procedure code 12001 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 12001 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less) and 27786 (closed treatment of distal fibular fracture (lateral malleolus); without manipulation).
Code 12001 is a column II code with a modifier indicator of 1 when billed with column I code 27786. Code 12001 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the standard of care for this monitoring of lymphedema is clinical exam.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided, and the current peer-reviewed medical literature there is no
documentation that the bioimpedance spectroscopy to monitor for lymphedema at issue in this case meets
Medicare criteria for medically reasonable and necessary. The current peer-reviewed medical literature does
not support that the testing is more accurate or effective than standard clinical monitoring for the detection of
lymphedema.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided March 31, 2021.
You asked the Plan to pay for the electrocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code has a column I / column II relationship with another code billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93010 has a column I / column II relationship with code 37252 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 an electrocardiogram (93010) provided March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided May
26, 2021, to May 29, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you don't have a copay
policy. The Plan denied your request. The Plan says the copayment was applied 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 $295
copayment per day, days 1 to 5 for inpatient hospital care. You have been asked to pay a total of $885 ($295 copayment x 3 days = $885) for the inpatient hospital stay.
This service 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 the inpatient hospital stay provided May 26, 2021, to May 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation.
You asked the Plan to pre-approve cardiac rehabilitation. You say that the member underwent a quadruple
coronary bypass surgery in 2016 and currently experiences and angina/angina equivalent symptoms such as
chest tightness and shortness of breath on exertion an overwhelming fatigue. The Plan denied your request. The
Plan says a formal cardiac rehabilitation program without a specified exercise prescription (compared to, for
example, a self-facilitated and self-monitored program) has not been established as standard of care toward
improved cardiac outcomes. It is therefore considered not medically necessary in this case.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab
programs. The services must be provided in a doctor's office or an outpatient hospital setting.
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 cardiac rehabilitation. Our reviewer
says that cardiac rehabilitation is not medically necessary. Our physician reviewer found that the clinical
documentation does not support that the requested intensive cardiac rehabilitation is medically necessary at this
time for the treatment of one or more of the conditions cited in the Medicare rules.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of cardiac rehabilitation have not been met. Therefore, we decided that the Plan
does not have to pre-approve cardiac rehabilitation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on March 18, 2021.
You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, and bitewing radiographic images. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, and bitewing radiographic images have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 22, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that these services were medically necessary. You would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.
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 an office visit provided on October 22, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided from March 10, 2021,
through April 12, 2021.
You asked the Plan to pay for incontinence supplies. You say that The Plan denied your request. The Plan says
this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided from
March 10, 2021, through April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 2, 2021, through May 7, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not in the Intensive Care Unit on May 2, 2021. The Plan denied your request. The Plan says the copayment was applied 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 $150 copayment each day for days 1-7 for inpatient hospital care. You have been asked to pay $750 ($150 x 5= $750) copayment for inpatient hospital care. The services at issue fall 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 hospital care provided from May 2, 2021, through May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99233) provided on September 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not received.
The Plan must follow Medicare rules. 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.
We looked at the file and Medicare rules. The documentation submitted does not contain medical records for date of service September 13, 2020. Without these records, it cannot be confirmed that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the services (99233) provided on September 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 30, 2021, through April 6, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not agree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per day for days 1-7 for inpatient hospital care. 

You have been asked to pay a $1750 ($250 x 7 = $1750) copayment for inpatient hospital care. The services at issue fall 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 hospital care provided from March 30, 2021, through April 6, 2021.