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

We decided that the Plan does not have to pre-approve the residual limb volume management and moisture
evacuation system (L5781).
You asked the Plan to pre-approve the residual limb volume management and moisture evacuation system. You
say that the item is medically necessary. The Plan denied your request. The Plan says the item 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 residual limb volume management
and moisture evacuation system. Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case.
Our physician reviewer found the available documentation in the case file does not contain documentation that
the enrollee has a medical need for the requested Residual Limb Volume Management System.
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 residual limb volume management and moisture evacuation system have not
been met. Therefore, we decided that the Plan does not have to pre-approve the residual limb volume
management and moisture evacuation system (L5781).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Diabetes Genomics next-generation sequencing (NGS) testing provided on August 25, 2021, billed with codes 81407, 81408, and 81479.
You asked the Plan to pay for the NGS panel. You say that these codes are covered by Medicare and should be paid. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that NGS panels for genetic cardiovascular issues may only be considered reasonable and necessary when certain criteria are met. It is noted that no genes currently meet criteria for coverage as outlined in the rules.
This testing was provided for a patient with diabetes to test for pathogenic variants related to cardiovascular disease. As noted in the rules, there are not currently any genes for which there is sufficient evidence to meet the LCD criteria for coverage. Therefore, we decided that the Plan does not have to pay for the Diabetes Genomics next-generation sequencing (NGS) testing provided on August 25, 2021, billed with codes 81407, 81408, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on March 9,
2021.
You asked the Plan to pay for the special anesthesia service. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator
of B.
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 99100 is not supported in the record. Specifically, CPT code 99100 has a status
indicator of B which means that the payment for this service is always bundled into the payment for another
service or procedure. Based on this information, we decided that Medicare rules for coverage of the special
anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the special
anesthesia service (99100) provided on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (85060) provided on August 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable.
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 payment for CPT code 85060 is not supported in the medical record. Specifically, code 85060 is assigned a PC/TC indicator of 8. This means that no TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate. No payment is recognized for code CPT 85060 furnished to hospital outpatients or non-hospital patients. 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 pay for the services (85060) provided on August 24, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the manual wheelchair you rented on August 25, 2021.
You asked the Plan to waive the coinsurance for the wheelchair. You say that this charge should be waived because you returned the wheelchair. The Plan denied your request. The Plan says you had the wheelchair in your possession until August 30m 2021, so you are responsible for this coinsurance.
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 wheelchair. The wheelchair falls within the durable medical equipment benefit category. The coinsurance applies even if you only have the item in your possession
for a portion of the month because durable medical equipment is charged on a per-month rental basis. 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 manual wheelchair you rented on August 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visits (99214 x 3) provided from
January 27, 2021, through June 30, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 15%
coinsurance using in-network providers that have the ability and are qualified to offer virtual behavioral visits.
You have been asked to pay $57.09. This includes the Plan allowed amount of $126.87 x 15%=$19.03 for the
virtual behavioral visits provided on January 27, 2021, March 31, 2021, and June 30, 2021. 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 office visits (99214 x 3) provided from January 27, 2021,
through June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
May 19, 2021, through May 20, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the
inpatient admission was not medically necessary.
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, 72-year-old male with a history of a seizure disorder and
no complicacy who presented with breakthrough seizure. The enrollee was hemodynamically stable, a
computed tomography (CT) of the head was negative and the Dilantin level was 2.7. The enrollee was treated
with Versed and Keppra in the emergency department (ED). Plan of care included a Neurology consult.
Neurology evaluated the enrollee, and he was discharged on May 20, 2021, on his baseline Dilantin dose and
planned for 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 enrollee's necessary hospital care
(including earlier ED 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 from May 19, 2021, through
May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on September 20,
2021.
You asked the Plan to waive the coinsurance for an office visit. You say that you are a disabled senior citizen
and should not be responsible for the charges due to the coverage you have. 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 provider and professional services.
You had an office visit on September 20, 2021. Therefore, you are responsible to pay your share of the cost-
sharing charges. The total allowed amount is $55.12 and 20% of that is $11.02.
You have been asked to pay the total coinsurance amount of $11.02 for an office visit. An office visit falls
within the physician/practitioner services, including doctor's office visits 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 office visit provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Device placement surgery for the
enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered
by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The enrollee has
chronic low back pain and lumbar spinal stenosis with neurogenic claudication.
The record indicates that the enrollee has multi-level degenerative disease including mild to moderate stenosis
at L4-L5, the level requested for treatment. The record does not document that the enrollee is not a indicated
for surgery at no more than two levels. The record does not include an assessment for potential osteoporosis in
an enrollee at high risk for osteoporosis. Our physician reviewer found that the enrollee's condition does not
meet criteria for coverage of these services.
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 Vertiflex Superion Device placement surgery for the enrollee.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to waive the cost share for the office visit on July 12, 2021. We decided that the
Plan does not have to waive the cost share for the nerve conduction study on July 12, 2021, and the office visit
on July 14, 2021.

You asked the Plan to waive the cost share for the office visits and the nerve conduction study. You say that
this was a clinic visit and not a hospital visit. The Plan says that the office visit on July 12, 2021, was
reprocessed from a $20 copayment to an $11.39 coinsurance and that you have been asked to pay the correct
cost-sharing amount for the remaining claims.

We decided that the Plan has to waive the cost share for the office visit on July 12, 2021.

The record shows you had a nerve conduction study during an office visit on July 12, 2021, therefore, the $0
copayment applies to the office visit.

The Plan says the claim was reprocessed and that you must pay $11.39 for the office visit on July 12, 2021.
However, based on the Plan contract, you cannot be asked to pay more than a $0 copayment for the office visit.
Therefore, we decided that the Plan has to waive the cost share for the office visit on July 12, 2021.

We also decided that the Plan does not have to waive the cost share for the nerve conduction study on
July 12, 2021, and the office visit on July 14, 2021.

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 $245
deductible which applies to the nerve conduction study on July 12, 2021. The Plan contract clearly says there is
a 10% outpatient coinsurance for each Medicare-covered diagnostic procedure or test. The Plan contract clearly
says there is a $20 copayment for the office visit.

Therefore, we decided that the Plan does not have to waive the cost share for the nerve conduction study on
July 12, 2021, and the office visit on July 14, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical
procedures (D9215) provided on September 8, 2021.
You asked the Plan to pay for the local anesthesia. You say that you feel that this service should be covered by
the Plan. The Plan denied your request. The Plan says this service is not covered under your Plan's
supplemental dental benefits.
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 local
anesthesia in conjunction with operative or surgical procedures (D9215) provided on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories 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 there is no medical need for a single power option group 3 power wheelchair.
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 the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found this request
exceeds the enrollee's needs. The documentation does not reveal that the enrollee is at high risk for
development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power
seating system to manage increased tone or spasticity therefore the request for power tilt exceeds the enrollee's
medical needs.
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 a group 3 power wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic leg with an advanced foot, ankle feature
(L5981 and L5968).
You asked the Plan to pre-approve the prosthetic leg with an advanced foot, ankle feature. You say that the
items are medically necessary. The Plan denied your request. The Plan says the items are 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 prosthetic leg with an advanced
foot, ankle feature. Our reviewer says that the requested items are not considered medically reasonable and
necessary in this case. Our physician reviewer found the requested items exceed the patient's medical need as
the documentation does not support that this patient will be a K3 ambulatory given their significant
comorbidity, ambulation of up to 15 minutes a day prior to amputation, and the possible need for a cane for
stability.
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 prosthetic leg with an advanced foot, ankle feature have not been met.
Therefore, we decided that the Plan does not have to pre-approve the prosthetic leg with an advanced foot,
ankle feature (L5981 and L5968).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on August 12, 2021.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. 

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services, medical examination and evaluation provided on July 29, 2021.

You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied your request. The Plan says the member must receive their treatment from network providers. The only exceptions are if the services are urgent or emergent when the network is not available or out of area dialysis services. In the event that specialized services are not available in the network, authorization is required.

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 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 ophthalmological services, medical examination and evaluation provided on July 29, 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 does not meet
criteria.
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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation
that you 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 service.