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

We decided that the Plan does not have to pay forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on July 17, 2019.You asked the Plan to pay forthe orthosis and sleeve. You say that the durable medical equipment is medically necessary.ThePlan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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. 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 forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you would like the plan to reconsider their denial.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 pre-approvefoot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (99213) provided on August 13, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were in-network providers available. The out-of-network provider was not preauthorized. The services were not emergent in nature.
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 outpatient mental health services (99213) provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 11, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this service was mandatory. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to provide power wheelchair upgraded electronics, joystick oregg switch.You asked the Plan to providethe power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377), Q logic joystick, and egg switch (K0108). You say that the enrollee needs the upgraded electronics, joystick and egg switch.The Plan denied your request. The Plan says there is not a medical need to control the power options through the joystick.The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are coveredif medically necessary.The file shows that the enrollee has normal range of motion and 5/5 strength in the right upper limb. Upper right limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. The egg switch and joystick are part of the requested electronic upgrade. This means that Medicare rules for coverage of the power wheelchair upgraded electronics, joystick and egg switchhave not been met.Therefore, we decided that the Plan does not have to providepower wheelchair upgraded electronics, joystick or egg switch.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of Zilretta.
You asked the Plan to pre-approve Zilretta. You say that your blood sugar has remained steady with the time-release Zilretta shots. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because medical studies have not proven that a repeat dose of Zilretta is safe and helpful for your condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Zilretta. Our reviewer says that you do not meet the Medicare criteria for the requested Zilretta. Our physician reviewer found the efficacy and safety of repeat administration of Zilretta has not been demonstrated, therefore the requested Zilretta is not medically 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve injections of Zilretta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer bench.
You asked the Plan to pre-approve a transfer bench. You say that the enrollee needs a transfer bench to bathe safely. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that transfer benches are not covered because they are not primarily medical in nature. While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleanings (D1110 x 2), the fluoride applications (D1206 x 2), and the invalid dental code (D0001) provided from February 2, 2017 to April 10, 2017.
You asked the Plan to pay for the 2 cleanings, 2 fluoride applications, and the invalid dental code. You say that your plan allows for 2 cleanings per year. The Plan denied your request. The Plan says 1 cleaning per calendar year is covered. The Plan says that the frequency limit for cleanings has been exceeded. The Plan also says that the application of fluoride and the invalid dental code are not covered services.
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 and cleanings are a covered service, the Plan only covers 1 cleaning per calendar year and therefore the frequency limit has been exceeded. Additionally, fluoride application and the invalid dental code are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cleanings (D1110 x 2), the fluoride applications (D1206 x 2), and the invalid dental code (D0001) provided from February 2, 2017 to April 10, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental appliance/sleeve (E0667).
You asked the Plan to pre-approve a pneumatic compression device and sleeve. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee has not had a four week trial of E0650 or E0651 and does not meet the criteria. Therefore, E0667 is non-covered when requested in conjunction with the non-approved code E0652.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental appliance/sleeve (E0667).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provided services were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan 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 laboratory services provided on September 27, 2019 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 shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have very bad balance and a history of falls. You say you are afraid that without the requested shower chair you will have another fall. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp to be provided.
You asked the Plan to pre-approve a wheelchair ramp. You say that the enrollee needs a wheelchair ramp. The Plan denied your request. The Plan says a wheelchair ramp is not medical in nature and not used in the home.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not cover home modifications. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp to be provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent (J3590).
You asked the Plan to pre-approve Dupixent. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Dupixent (J3590).
Benefits for Dupixent 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX injections for the enrollee.
You asked the Plan to pre-approve Supartz FX. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary for the enrollee in this case. The provided medical records do not indicate that the enrollee has tried and failed Monovisc and Orthovisc or that they would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX injections for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 19, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and segmented appliance/sleeve (E0667).
You asked the Plan to pre-approve the Flexitouch device and appliance/sleeve. You say that the enrollee had poor results with a basic and now needs the Flexitouch device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. In this instance, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person
fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Based on this information, we decided that Medicare rules for coverage of the Flexitouch device and appliance/sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and segmented appliance/sleeve (E0667).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on December 30, 2018.
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 the claim is not billed correctly per the relevant guidelines.
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed with a valid value code. The required data element - value code 61 - was not found entered on the home health claim. 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 home health services provided to the enrollee on December 30, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 4, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services were not supported.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 6, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you have never been billed for laboratory services before. The Plan denied your request. The Plan says the copayment 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 $20 for Medicare-covered laboratory tests. You have been asked to pay $18.62, which is less than the standard $20 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Static or dynamic ankle foot orthosis (L4396).
You asked the Plan to pay for the orthosis. You say that guidelines for L4396, medically unlikely edits approves up to quantity of 2 during qualified time frame. The clinical documentation provided will support medical necessity of this claim. The Plan denied your request. The Plan says the units for this service exceeds the allowed units. Maximum benefit available for this service has been paid.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code L4396 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for Static or dynamic ankle foot orthosis (L4396).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placements of implant body: endosteal implants (code D6010 x8) and abutment supported porcelain fused to metal crowns (code D6059 x7).
You asked the Plan to pre-approve the endosteal implants and abutment supported crowns. The Plan denied your request. The Plan says these services are not listed as covered services.
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 pre-approve surgical placements of implant body: endosteal implants (code D6010 x8) and abutment supported porcelain fused to metal crowns (code D6059 x7).