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

We decided that the Plan does not have to reimburse you for the Spitfire Scout 4 travel scooter provided on September 7, 2018 by out of network provider.
You asked the Plan to reimburse you for the power mobility device. You say that you did not realize a power scooter would be covered through the plan. The Plan denied your request. The Plan says you did not have a physician order or prior authorization for the scooter.
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 reimburse you 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 has network providers available who can provide the item at issue in this appeal. You did not have a physician order. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to reimburse you for this item. Therefore, we decided that the Plan does not have to reimburse you for the Spitfire Scout 4 travel scooter provided on September 7, 2018 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT Code K0823).
You asked the Plan to pre-approve the POV. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. The mobility evaluation concluded that functional mobility deficits can be resolved by a walker and that home environment is not suitable for a POV. POV's are not covered by Medicare for use outside of the home. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT Code K0823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (HCPCS E0667) provided to the enrollee on August 6, 2019.
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order for the billed item; therefore, the billed service and modifiers cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code E0667 is "Segmental pneumatic appliance for use with pneumatic compressor, full leg." We find that HCPCS code E0667 is not supported in the medical record. Specifically, there is no valid physician order in the case file. The code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (HCPCS E0667) provided to the enrollee on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder, elbow, hand and wrist orthosis (L3960) provided on October 1, 2018.
You asked the Plan to pay for the orthosis. You say that you would like reconsideration as the orthosis is medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician and the record does not identify the member's originating site.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. Additionally, there is no record of an established relationship between the member and ordering physician. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for shoulder, elbow, hand and wrist orthosis (L3960) provided on October 1, 2018.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not have a history of osteoporotic fracture, or has had previous treatment, contraindication, or intolerance to Zoledronic Acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our physician reviewer found that the enrollee has a diagnosis of age-related osteoporosis with current pathological fracture. The Plan requires a trial of drug Zoledronic Acid, or a history of osteoporotic fracture before they will approve the requested drug. The documentation does not support that Zoledronic acid would likely be less effective, or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from April 17, 2019 through April 20, 2019 by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee admitted to an in-network provider on April 17, 2019 and discharged on April 20, 2019. The enrollee was asked to pay a $220 copayment per day from April 17, 2019 through April 19, 2019, days 1-3 of the enrollee's inpatient hospital care. The enrollee was discharged on April 20, 2019 and there was no copayment charge for the day of discharge. Per the enrollee's contract there is a $220 copayment per day required for days 1-7. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from April 17, 2019 through April 20, 2019 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on August 22, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorizationas outlined in the enrollee's EOC.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve theservices 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 forthe medical services provided by an out-of-network provider on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services with an out-of-network dermatologist.
You asked the Plan to pre-approve the out-of-network dermatology services. You say that if you do not have this procedure you could suffer from a heart attack. You say that if your sternum is not repaired you do not have adequate protection around your heart and internal organs. You say that you need to have this procedure with the original treating provider due to it being a basic fix, however, without the procedure you will have less quality of life. The Plan denied your request. The Plan says there are providers in the enrollee's assigned provider network who can provide the care being requested.
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 pre-approved care. 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 medical services with an out-of-network dermatologist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.  You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Botox is covered for specific indications only. 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 services are not medically necessary. Our physician reviewer found the enrollee has dystonia of extremity and received Botox injections for painful legs and moving toes syndrome. The injections were stopped due to a lack of perceived benefit. After staying off the Botox for several cycles, the enrollee experienced significant worsening of her symptoms. The diagnosis of extremity dystonia with painful legs and moving toes is not covered by Medicare and the documentation in the medical record does not clearly establish that Botox is medically reasonable and necessary for the enrollee in this case. 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 Botox the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services provided on July 16, 2019 by the out of network provider.  You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 has network providers available who can provide 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 rest home visit services provided on July 16, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the Foot with 3 views (73630) provided May 22, 2018.  You asked the Plan to pay for the X-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the records submitted to not support the services 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 73630 is not supported in the medical record. Specifically, the records provided do not show how many views were taken. Based on this information, we decided that Medicare rules for coverage of the X-ray have not been met. Therefore, we decided that the Plan does not have to pay for an X-ray of the Foot with 3 views (73630) provided May 22, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Exjade for the enrollee.  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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Exjade for the enrollee.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implanted device.
You asked the Plan to pre-approve implanted device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services 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 implanted device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have back pain. The requested device is experimental. More research is needed to show the safety and efficacy of the implanted spinal device. Therefore, you do not meet criteria for the requested 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 implanted device have not been met. Therefore, we decided that the Plan does not have to pre-approve implanted device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for robotic surgical techniques (HCPCS S2900) provided to the enrollee on July 25, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code S9200 is "Surgical techniques requiring use of robotic surgical system (List separately in addition to code for primary procedure)." We find that HCPCS code S9200 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 robotic surgical techniques (HCPCS S2900) provided to the enrollee on July 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 31, 2019 to October 19, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number, the Proof of Delivery did not include details to corroborate the Delivery Ticket and the Physician Order did not specify what supplies are ordered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation and valid physician order for the items at issue in this appeal. The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 31, 2019 to October 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76770) provided on July 31, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that your husband has Parkinson's and on the advice of his family physician went in for sonogram. He wasn't informed there would be a copayment so he was surprised when he received a bill for $40.00. You say he would have walked out if he had been advised of additional charges. The Plan denied your request. The Plan says outpatient diagnostic services have a $40 copayment for each basic imaging service including ultrasounds.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for outpatient diagnostic services. The enrollee has been asked to pay a $40 copayment for an ultrasound. This service falls within the outpatient diagnostic services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound (76770) provided by on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on May 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on May 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Crestor for the enrollee.  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 self-administered drugs are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Crestor for the enrollee.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage to be provided.  You asked the Plan to pre-approve additional routine transportation mileage. You say that the enrollee needs transportation. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation mileage is correct, because routine transportation beyond 50 miles per one-way trip is not covered by the Plan.
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 additional routine transportation mileage when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. 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 additional routine transportation mileage to be provided.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services provided on July 19, 2019 by an out of network provider.  You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 has network providers available who can provide 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 rest home visit services provided on July 19, 2019 by the out of network provider.