Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit (G0463) rendered by the out of network (OON) provider on December 5, 2019. You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network provider, without prior authorization. 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit (G0463) rendered by the out of network (OON) provider on December 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to see your otolaryngologist.
You asked the Plan to pre-approve routine transportation to see your otolaryngologist. You say that you need this transportation for monitoring of your tumor. The Plan denied your request. The Plan says trips that exceed 50 miles are 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 routine transportation trips that do not exceed 50 miles. We looked at your request, the records in the case file, and the rules. The trip you have requested is 214 miles. This exceeds the Plan's 50-mile limit. 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 to see your otolaryngologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on October 9, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 8, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services rendered on December 17, 2019.
You asked the Plan to waive the copayment for these services. You say that you don't understand the increase in price. 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 $40 copayment for each Medicare-covered podiatry visit.
Review of the file shows that you received podiatry services on December 17, 2019. You have been asked to pay a $40 copayment for these services. These services fall within the Medicare-covered podiatry visit 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 podiatry services rendered on December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

You asked the Plan to pre-approve Supartz FX. You say that the Supartz FX is medically necessary.The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.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 coverage criteria has not been met. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason why they would be contraindicated 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 Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approve Supartz FX (J7321).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 18, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee was on hospice. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on December 13, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says the appropriate initial evaluation for weight loss must include evaluation of upper and lower digestive tracts, and only if this initial evaluation is completed and does not identify the cause of the weight loss.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has blood in his stool, weight loss and anemia. There was normal chest x-ray. The GI consult is pending. CT of the chest is not indicated prior to determining if symptoms are GI related especially given the report of a normal chest x-ray.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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornerve conduction studies (95910) and needle electromyography (95886) provided on November 12, 2019.You asked the Plan to pay forthe nerve conduction studies and needle electromyography. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does 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.In this case, the CPT Code Manual definition of code 95910 is nerve conduction studies; 7-8 studies.The CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the nerve conduction studies and needle electromyography. Our reviewer says that CPT code 95910 does not meet criteria for billing or reimbursement consideration. The technical report did not include documentation of nerve conduction studies for 7-8 studies. Our reviewer found CPT code 95886 does not meet criteria for billing or reimbursement consideration. Documentation submitted was reviewed, no documentation found to support that a complete needle electromyographywas done.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies and needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay fornerve conduction studies (95910) and needle electromyography (95886) provided on November 12, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the intraoperative neuromonitoring services provided on
August 2, 2019.
You asked the Plan to pay for the neuromonitoring services. You say that intraoperative neuromonitoring was
requested to maintain the enrollee's neurological integrity during surgery. The Plan denied your request. The
Plan says that the claim is the financial responsibility of the behavioral health provider.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The records provided show the enrollee received intraoperative neuromonitoring services. Neuromonitoring
services provided during surgery are not behavioral health services. The Plan has not made reasonable and
diligent efforts to gather and forward to us information regarding their decision to deny your request.
Therefore, we decided that the Plan has to pay for the intraoperative neuromonitoring services provided on August 2, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee. You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of the medical necessity of 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 the injection. Our reviewer says that the requested injection does not meet the step therapy criteria. Our physician reviewer found there is no indication of a trial and failure or Orthovisc or Monovisc. The provided medical records do not indicate that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee was found to have diffuse large B-cell lymphoma (DLBCL) on upper endoscopy. A PET scan is the standard of care in staging patients with DLBCL. The PET scan is reasonable and medically necessary at this time. 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 been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) scan
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Home Ventilator (E0466).You asked the Plan to pre-approvethe ventilator. You say that the ventilator is medically necessary.The Plan denied your request. The Plan says rules for coverage are not met.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 ventilator. Our reviewer says that the home ventilator is not medically necessary. Our physician reviewer found the records provided do not show hypercarbia. The enrollee's needs would likely be met with BiPAP.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 ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea HomeVentilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on September 23, 2019 from an out-of-network provider.You asked the Plan to pay forthe hearing aids. You say that you are requesting reimbursement of services rendered.The Plandenied your request. The Plan says the provider is not part of the network.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. The provider is not in-network and your EOC clearly states, you may choose to order hearing aids either through the Plan's hearing aid supplemental vendors. Hearing aids ordered through providers other than the Plan's hearing aid supplemental vendors are not covered.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased on September 23, 2019 from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the4-week trial using the basic pump that Medicare requires.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 preapprove a pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on January 3, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department (ED) services provided on June 15, 2019.
You asked the Plan to pay for the ED visit. You say that you feel that this should be covered because you had no other option but to go to the ED. The Plan denied your request. The Plan says that this service was provided for dental pain. Medicare does not cover care for anything related to the teeth.
The Plan must follow Medicare rules. Medicare rules say that dental services are not covered. However, health plans must pay for services that a prudent layperson would believe immediate attention was needed to prevent harm to his/her health. In this case, there is no documentation that any treatment or care of the teeth or supporting structures was provided during this ED visit. The visit was provided in order to treat pain and possible infection, which are medical conditions. This visit would not be considered a dental service and is considered an emergency situation. Therefore, we decided that the Plan has to pay for the emergency department (ED) services provided on June 15, 2019.
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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forthe elastomeric infusion pump provided on November 7, 2019.You asked the Plan to pay forthe infusion pump. The Plan denied your request. The Plan says that that this is not covered by Medicare.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the infusion pump by a contract provider. The file does not show that the Plan provided notice that the infusion pump would not be covered. Under Medicare rules, this means the infusion pump is considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe elastomeric infusion pump provided on November 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aransep.
You asked the Plan to pre-approve the Aransep. You say that the Aransep is medically necessary. The Plan
denied your request. The Plan says step therapy requirements have not been met.
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 the Aransep. Our reviewer says that
coverage criteria has not been met. Our physician reviewer found the enrollee has not trialed the plan preferred
drug, Retacrit, and the records show no reason why Retacrit would be ineffective or unsafe 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 the Aransep have not been met. Therefore, we decided that the Plan does not
have to pre-approve Aransep.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 20, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered on November 20, 2019.