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

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the medical records provided support the need for the requested semi-electric hospital bed. The Plan denied your request. The Plan says the documentation does not show that the criteria for coverage have been met. The Plan says that the requested did not include a physician order.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. 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 semi-electric hospital bed. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The provider's notes do not indicate a need for upper body elevation over 30 degrees or a clear need for this bed. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this enrollee. 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to waive the copayments for hearing tests, office visit, and endoscopy. You say that you do
not agree with the amount you are being charged. The Plan says that the copayment amounts you are being
charged are correct.
We decided that the Plan has to waive the copayment for nasal endoscopy.
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 $40
copayment for each specialist office visit, including surgery services furnished in an office. The nasal
endoscopy you received in considered to be a surgical service; therefore, this is included in the office visit copayment and a separate copayment does not apply.
The Plan says that you must pay $50 copayment for nasal endoscopy, in addition to a $40 specialist visit copayment. Based on your contract with the Plan, however, you cannot be asked to pay more than the $40 copayment which you have already been asked to pay. Therefore, we decided that the Plan has to waive the copayment for nasal endoscopy.
We also decided that the Plan does not have to waive the copayments for hearing tests and office 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 $40 copayment for hearing tests and $40 copayment for specialist visit. Your total copayment amount is therefore $80. Therefore, we decided that the Plan does not have to waive the copayments for hearing tests and office visit.
Therefore, we decided that the Plan has to reduce your total cost-sharing responsibility for this claim from $130 to $80 copayment.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation for one-way trips that exceed the Plan's 60-mile trip limit
You asked the Plan to pre-approve routine transportation for one-way trips that exceed the Plan's 60-mile trip limit. You say that you have anxiety and pain and cannot drive the distance required for the trip. The Plan denied your request. The Plan says the trip exceeds 60 miles and therefore is not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the trip does not exceed 60 miles. We looked at your request, the records in the case file, and the rules. In this case we verified that the requested trip is greater than 60 miles each way. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation for one-way trips that exceed the Plan's 60-mile trip limit
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a coronavirus test (U0003) provided November 24, 2020.
You asked the Plan to pay for a coronavirus test. You say that you would like this claim reprocessed by the Plan. The Plan denied your request. The Plan says the provider needs to bill Original Medicare as the enrollee was in hospice care at that time.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for a coronavirus test (U0003) provided November 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit provided by a Psychology Doctor (Ph. D.) on March 15, 2021.
You asked the Plan to pay for mental health visit. You say that your provider performed medically necessary services to the enrollee in good faith. The Plan denied your request.
The Plan says the denial of payment for this service is correct, because this provider is a Psychology Doctor and there is no documented contact with the enrollee's attending/primary care physician or referring physician listed on the claim.
The Plan must follow Medicare rules. Medicare rules say that Medicare may cover services performed by a provider qualified with a Psychology Doctoral degree under certain circumstances, including that the provider must attempt to consult the enrollee's attending or primary care physician. We looked at the file and Medicare rules. The documentation submitted does not include a consultation or attempt to consult the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of mental health visit have not been met. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided by a Psychology Doctor (Ph. D.) on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine and supplies provided on January 08, 2018, May 15, 2018, August 10, 2018, and October 26, 2018 by an out-of-network (OON) provider.
You asked the Plan to pay for the CPAP. You say that you did not know that you had to get the supplies from an out of network provider. The Plan denied your request. The Plan says there were network providers available to you to receive services from.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine and supplies provided on January 08, 2018, May 15, 2018, August 10, 2018, and October 26, 2018 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on March 4, 2021.
You asked the Plan to pay for foot orthotics. You say that one of your legs are shorter than the other. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on March 4, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 10, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 10, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on May 17, 2021.
You asked the Plan to waive the copayment for the cystoscopy. You say that you were not in an operating room and you went to an office for five minutes. You say you should not get charged this much The Plan denied your request. The Plan says you have been asked to pay 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 $475 copayment for each Medicare-covered outpatient hospital visit or hospital outpatient surgical facility visit. You have been asked to pay a $475 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
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 cystoscopy provided on May 17, 2021.
Your complaint about the benefit structure 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 9, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is medically necessary. The Plan denied your request. The Plan says the requested pneumatic compression device is not 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. 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. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialized lower limb prosthetic cover (CPT code L5962) and flex-walk system or equal (CPT code L5981).
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied your request. The Plan says it 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 items. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for K3 prosthesis exceeds your need and does not meet Medicare criteria as reasonable and necessary. There is no documentation of unusually harsh environmental situations for which a specialized lower limb prosthetic cover (L5962) is required and for which a standard prosthetic cover (L5704) would be insufficient. The review has determined that your function level is 3 or higher. There are no documented special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve a specialized lower limb prosthetic cover (CPT code L5962) and flex-walk system or equal (CPT code L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty walker with a seat attachment (E0158, E0149).
You asked the Plan to pre-approve the heavy-duty walker with a seat attachment. You say that the walker is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for patients who weigh more than 300 pounds. We looked at the file and Medicare rules. The record shows the enrollee weighs less than 300 pounds. Based on this information, we decided that Medicare rules for coverage of the heavy duty walker with a seat attachment have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker with a seat attachment (E0158, E0149).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Eylea injection provided April 30, 2021.
You asked the Plan to waive the coinsurance for Eylea injection. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total cost share of $367.55 for Eylea injection ($1837.74 Medicare-allowed amount x 20% coinsurance). Eylea injection falls within the Medicare Part B prescription drugs 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 Eylea injection provided April 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport rendered on April 22, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree 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 for each one-way Medicare-covered ambulance ground trip.
Review of the file shows that you received an ambulance transport on April 22, 2021. You have been asked to pay a $250 copayment for these services. These services fall within the one-way Medicare-covered ambulance ground trip 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 ambulance transport rendered on April 22, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the billed services 33210, 33249 and 93641 provided June 30, 2020, to July 2, 2020.
You asked the Plan to pay for the billed services 33210, 33249 and 93641. You say that you would like these claims reprocessed. The Plan denied your request. The Plan says the claims have denied correctly in this case.
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 the billed service 33210 has a bundled relationship with 33241 and cannot be paid as billed. This code cannot be paid as a separate line item. Regarding 33249 and 93641, the records indicate that major surgery was performed on June 30, 2020. These procedures would be considered as bundled in the global surgery package according to Medicare rules. Based on the claims submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the billed services 33210, 33249 and 93641 provided June 30, 2020, to July 2, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose moni