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 (E2300, E2311, E2313, E2377).  You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the requested power wheelchair and accessories are reasonable and medically necessary except for E2300, E2311, E2313, E2377.  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 you require 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.). You do not need 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. Your right upper extremity strength and function with the ability to groom independently supports that the patient 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 (E2300, E2311, E2313, E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from February 18, 2021, to February 26, 2021.  You asked the Plan to pay for the inpatient psychiatric care. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee was no longer a danger to self or others. The Plan says that the enrollee was medically stable. The Plan also says that the enrollee had improved with treatment and no longer needed 24-hour care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 the inpatient psychiatric care. Our reviewer says that inpatient psychiatric care was not medically necessary. Our physician reviewer found the provided documentation did not indicate that it was medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. The reviewer found that the enrollee did not have dangerousness to herself or others and was compliant with her treatment. Therefore, the reviewer found that the inpatient psychiatric care was 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 inpatient psychiatric care have not been met. Specifically, the file shows that the enrollee was not a danger to herself or others. Therefore, we decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from February 18, 2021, to February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on March 23, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.   We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator provided on May 10, 2020, to June 10, 2020.  You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you were never told of the cost or saw a rental agreement. 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 DME and related supplies.   You received an automatic external defibrillator on May 10, 2020. The total allowed amount is $2,899.50 and 20% of that is $579.90.   You received an automatic external defibrillator on June 10, 2020. The total allowed amount is $2,899.50 and 20% of that is $579.90.  The total amount you owe is: $1,159.80.   You have been asked to pay the total coinsurance amount of $1,159.80 for an automatic external defibrillator. An automatic external defibrillator falls within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator provided on May 10, 2020, to June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 2 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 a Group 2 PWC 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 criteria for coverage are not met. Our physician reviewer found the submitted records show that you have a mobility deficit but are able to perform self-care activities, light cooking, and cleaning. You are able to help your mobility deficit with a manual wheelchair and a walker. While you may be able to safely use the requested power wheelchair, the documentation does not show that it will significantly improve your participation in mobility-related activities of daily living (MRADLs) in the home.  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 a Group 2 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter coded as E1399.  You asked the Plan to pre-approve a power scooter. You say that this should never have been denied because your feet hurt so much that it is difficult for you to walk. The Plan denied your request. The Plan says the records do not support that you meet the criteria for a power operated vehicle.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power scooter. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that the enrollee has a mobility deficit that interferes with mobility related activity of daily living (MRADL) and is unable to be alleviated by a manual wheelchair. Her physical exam notes that normal gait, sensory, motor, reflexes are intact. The enrollee does not want to use a manual wheelchair but there is no contraindication for this. The documentation does not support that the use of a power scooter coded as E1399 will significantly improve participation in MRADLs in the home and the criteria has not been met per Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.3(B).  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter coded as E1399.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the computed tomography (CT) scan analysis (0503T) provided on July 8, 2021.  You asked the Plan to waive the cost share for the CT scan analysis. You say that you disagree with the copayment as charged. The Plan denied your request. The Plan says the cost share has processed correctly in this case.  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 $160 copayment for radiological diagnostic services.   You have been asked to pay a $160 copayment for the CT scan analysis. This service falls within the radiological diagnostic services 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 cost share for the computed tomography (CT) scan analysis (0503T) provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on February 21, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered.  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. In this case, records were not provided by non-contract provider. Without supporting records, it cannot be confirmed that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation services are medically necessary for the enrollee to regain their prior level of function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acupuncture services (97813) provided on July 22, 2021, by an OON provider.  You asked the Plan to pay for the acupuncture services. You say that you were not aware you needed prior authorization for these services. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that certain services are excluded from the point-of-service benefit.  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 as acupuncture services are specifically not covered under the point-of-service benefit. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97813) provided on July 22, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on June 24, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on June 24, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to waive the copayment for a urine complicity measure. We decided that the Plan does not have to waive the copayments for an ultrasound and a specialist visit.   You asked the Plan to waive the copayments for a urine complicity measure, an ultrasound, and a specialist visit. You say that you disagree with the charges and will stop your screenings if you have to pay this much each time. The Plan says that the claims were processed correctly, and you are being charged the correct amount.  We decided that the Plan has to waive the copayment for a urine complicity measure.   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 $25 copayment for a specialist visit.  The record shows that you received a urine compacity measure, at a specialist's office on June 28, 2021. A urine compacity measure is considered an outpatient surgical procedure. Because services were rendered in a specialist's office, this service would be covered under a specialist's copayment, which the record shows you were already charged. Therefore, we decided that the Plan has to waive the copayment for a urine complicity measure.   We also decided that the Plan does not have to waive the copayments for an ultrasound and a specialist visit.  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 $155 copayment for ultrasounds. Your contract with the Plan also clearly says that you must pay a $25 copayment for specialist visits.  You received an ultrasound on June 28, 2021. Therefore, you are responsible to pay the $155 copayment.   You received a specialist visit on June 28, 2021. Therefore, you are responsible to pay the $25 copayment.   The total amount you owe is: $180.   Therefore, we decided the Plan does not have to waive the copayments for an ultrasound and a specialist visit.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for computed tomography, head or brain (70460) computed tomography, soft tissue neck (70491) provided April 22, 2020.  You asked the Plan to pay for the radiology service. You say that the claim was originally filed in a timely manner. Please see the attached proof of timely filing for reprocessing. The Plan denied your request. The Plan says claim was received past the timely filing limitation.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the radiology service was not filed until July 22, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for computed tomography, head or brain (70460) computed tomography, soft tissue neck (70491) provided April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physician's services for an eye exam provided on May 4, 2021, and July 29, 2021.  You asked the Plan to waive the copayment for physician's services. The Plan denied your request. The Plan says the claims 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 $40 copayment for Vision Care, Medicare-covered Vision Services-Specialist Office.   You have been asked to pay a $40 copayment for physician's services. The physician's services falls within the Vision Care, Medicare-covered Vision Services-Specialist Office 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 physician's services for an eye exam provided on May 4, 2021, and July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital care (99233) provided November 27, 2020.  You asked the Plan to pay for the initial hospital care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the same service by the same provider was already paid.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 99233 is not supported in the medical record. Specifically, this service has already been paid by the Plan and this claim is a duplicate of this paid claim. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the hospital care (99233) provided November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network general surgeon.  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 available from network providers.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network general surgeon.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network imaging services provided to the enrollee on June 2, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 out of network imaging services provided to the enrollee on June 2, 2021.