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

 We decided that the Plan does not have to pre-approve a power seat elevation system, back up camera and camera brackets for the enrollee.  You asked the Plan to pre-approve a power seat elevation system, back up camera and camera brackets for a power wheelchair. You say that this power wheelchair and requested accessories are medically necessary. The Plan denied your request. The Plan says while the power wheelchair and Medicare allowed accessories were approved, the power seat elevation system, back up camera and camera brackets are not covered by Medicare or the Plan.  The Plan follows Medicare rules. Medicare rules say that a power seat elevation system is not covered. Medicare rules say that equipment that does not serve a medical purpose are not covered. A power seat elevation system and back up camera and brackets are statutorily excluded from coverage. While these items may be helpful to the enrollee, they are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, back up camera and camera brackets for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home ventilator (E0466) and heated humidifier (E0562) provided on June 7, 2021.  You asked the Plan to pay for the durable medical equipment. You say that the enrollee's hospice benefit was revoked prior to the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on June 6, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the home ventilator (E0466) and heated humidifier (E0562) provided on June 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided on May 7, 2020.  You asked the Plan to pay for the home health services. You say that timely filing was not missed. You also say that the original claim was never paid. The Plan denied your request. The Plan says the claim was processed correctly.  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 home health services was not filed until September 13, 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 the home health services provided on May 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Repair blood vessel, direct; lower extremity (35226-GC x2) provided on August 20, 2021.  

You asked the Plan to pay for code 35226-GC x2. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  

We find that CPT code 35226-GC x2 is not supported in the medical record. This code has a bilateral surgery indicator of 1. This means the code should be reported with 1 unit of service and modifier 50 (bilateral modifier) or an appropriate anatomical modifier (right or left) to be considered for payment. Based on this information, we decided that Medicare rules for coverage of code 35226-GC x2 have not been met. Therefore, we decided that the Plan does not have to pay for the Repair blood vessel, direct; lower extremity (35226-GC x2) provided on August 20, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 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. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an arthrocentesis injection of the major joint or bursa (shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610) rendered on June 10, 2021.  You asked the Plan to waive the copayment for an arthrocentesis injection of the major joint or bursa (shoulder, hip, knee, subacromial bursa); without ultrasound guidance. You say that you saw your doctor for a short outpatient visit for a procedure service and soon received a bill. You also say you had this procedure before and never was charged so much. The Plan denied your request. The Plan says you were charged 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 $370 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.   You have been asked to pay $314.68, which is less than the $370 copayment for an arthrocentesis injection of the major joint or bursa (shoulder, hip, knee, subacromial bursa); without ultrasound guidance. An arthrocentesis injection of the major joint or bursa (shoulder, hip, knee, subacromial bursa); without ultrasound guidance falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 an arthrocentesis injection of the major joint or bursa (shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610) rendered on June 10, 2021.   Your complaint about the potentially poor customer service from 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: Transportation
Decision: Favorable

 We decided that the Plan has to pay for non-emergency ambulance (A0428), and ground mileage (A0425) provided on August 24, 2021.  You asked the Plan to pay for the transportation services. You say that you were not aware that prior authorization was needed. You also say that the transportation was necessary. The Plan denied your request. The Plan says that the transport was not medically necessary. The Plan also says there were not pad claims by the receiving facilities.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 transportation services. Our reviewer says that the transportation services were medically necessary. Our physician reviewer found the medical records provided indicate that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on August 24, 2021 due to the enrollee's dementia with combativeness and need or possible need for restraints. The reviewer found that the enrollee required the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance could provide for safe transport on August 24, 2021 due to their dementia with combativeness and need or possible need for restraints. Therefore, the reviewer found that the ambulance transport on August 24, 2021 was medically reasonable and 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 transportation services have not been met. Specifically, the file shows that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee due to their condition. Therefore, we decided that the Plan has to pay for non-emergency ambulance (A0428), and ground mileage (A0425) provided on August 24, 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 waive the out of network cost share for the oral exams (D0120 x 2), cleanings (D1110 x 2), and bitewing x-rays (D0274) provided from March 15, 2021, to September 13, 2021.  You asked the Plan to waive the out of network cost share for the dental services. You say that you should not have to pay the balance for these services. The Plan denied your request. The Plan says out of network dentists may bill you for any amount greater than what the plan pays the 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, out of network dentists may bill you for any amount greater than what the plan pays the provider. Therefore, we decided that the Plan does not have to waive the out of network cost share for the oral exams (D0120 x 2), cleanings (D1110 x 2), and bitewing x-rays (D0274) provided from March 15, 2021, to September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on October 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that services were provided to the enrollee. The Plan denied your request. The Plan says the provider is a non-participating provider, and the referring doctor is also a non-participating 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 laboratory services provided on October 16, 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 eye refraction (92015) provided on October 18, 2021.  You asked the Plan to pay for the eye refraction. You say that this eye refraction was necessary following insertion of IOLs with your cataract surgery. The Plan denied your request. The Plan says eye refractions are not covered by Original Medicare. The Plan offers an additional benefit which covers eye refractions, but these services will only be covered when performed by a provider in the Plan's specified routine vision network as part of a routine eye exam. The exam in this case was conducted for medical reasons; therefore, the refraction is not covered by Medicare or by the Plan.  The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.  The services you asked the Plan to pay for are considered routine vision services and are not covered by Original Medicare. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the office visit services (99213) provided on June 10, 2021.  You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that global surgical payments include payment for many services related to the surgery. Medicare rules say that services of other physicians are not included in the global surgical package unless the surgeon and other physician agree on the transfer of care. Medicare rules also say that plans must make reasonable and diligent efforts to gather and forward information to the IRE.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit services have been met. Specifically, the office visit services were rendered by a different provider than that which provided the initial procedure. The record does not include evidence of a transfer of care agreement. Additionally, the office visit was unrelated to the diagnosis for which the initial procedure was performed. Therefore, we decided that the Plan has to pay for the office visit services (99213) provided on June 10, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for wound care treatment provided from May 4, 2021, to June 28, 2021.  You asked the Plan to waive the copayments for wound care treatment. You say that the copayment applied is excessive. The Plan denied your request. The Plan says the enrollee was charge less than the copayment of what the max allowable was so the proper copayments were 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 $275 copayment for each Medicare-covered visit to an ambulatory surgical center or an outpatient hospital facility. The total allowable amount for each visit was $130.07 which is less than the copayment amount of $275. Therefore $130.07 was the copayment amount for each visit which totaled $1,040.56 ($130.07 x 8 visits).  You have been asked to pay a $1,040.56 copayment for wound care treatment. The wound care treatment falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for wound care treatment provided from May 4, 2021, to June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (88120) provided March 25, 2021.  You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this service was for screening purposes and is non-covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing (88120) provided March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee orthosis (L1830) provided on March 2, 2021.  You asked the Plan to pay for the knee orthosis (L1830). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. In this case, there were no medical records provided for review to determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1830) provided on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that you were unable to obtain prior authorization as you are not a contracted provider, and you provided services in good faith that you would be reimbursed. You also say that the patient's physician ordered the testing due to the patient's history of chronic urinary tract symptoms that have failed to resolve with standard treatment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 laboratory services provided on October 27, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676).  

You asked the Plan to pay for a pneumatic compression device. You say that the device was medically necessary. The Plan denied your request. The Plan says this device is non-covered.  

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an ultrasound (76942) provided August 9, 2021.  You asked the Plan to pay for the ultrasound. You say that this service was medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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.  We find that CPT code 76942 is not supported in the medical record. Specifically, the code billed has a Professional Component / Technical Component indicator of 1. This service requires a modifier (26) when billed in the outpatient setting. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76942) provided August 9, 2021.