Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient mental health services. You say that you would like reconsideration as you believe these services should be covered by the Plan. The Plan denied your request. The Plan says the utilization of in network providers unless the plan pre-approves out of network services in non-emergent situations.
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 medical services provided on October 3, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP and supplies provided from August 19, 2019 to October 19, 2019.
You asked the Plan to waive the coinsurance for the CPAP and supplies. You say that the machine was not working for three months so you should not be financially responsible. The Plan denied your request. The Plan says that the coinsurance 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 20% coinsurance for Medicare-covered durable medical equipment and related supplies. You have been asked to pay a 20% coinsurance for the CPAP and supplies. The CPAP and supplies fall within the Medicare-covered durable medical equipment and related 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 coinsurance for the CPAP and supplies provided from August 19, 2019 to October 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the compounded baclofen, bupivacaine, gablofen, and clonidine provided for an implanted infusion pump on February 27, 2019 billed on three line items with a total of 11 units.You asked the Plan to pay for the compounded drugs. You say that each unit billed for the drugs provided is correct and should be paid.The Plan denied your request. The Plan says multiple units of code J7999 may not be billed. A single unit is payable for all compounded drugs provided.The Plan must follow Medicare rules. Medicare rules say that billing for compounded drugs requires that one unit of J7999 on a single line item be billed. The specific drugs and amounts are then documented in Box 19 of the claim, or its electronic equivalent. In this case, each compounded drug was reported on a separate line item with multiple units. This is not correct billing for Medicare payment of compounded drugs.Therefore, we decided that the Plan does not have to pay for the compounded baclofen, bupivacaine, gablofen, and clonidine provided for an implanted infusion pump on February 27, 2019 billed on three line items with a total of 11 units.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amyotrophic Lateral Sclerosis (ALS) Advanced genetic testing panel.You asked the Plan to pre-approve Amyotrophic Lateral Sclerosis (ALS) Advanced genetic testing panel. You say that the requested ALS Advanced genetic testing panel is medically necessary.The Plan denied your request. The Plan says the requested ALS Advanced genetic testing panel 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 Amyotrophic Lateral Sclerosis (ALS) Advanced genetic testing panel. Our reviewer says that the requested ALS Advanced genetic testing panel is not medically necessary. Our physician reviewer found in this case the enrollee has been given a diagnosis of ALS. A diagnosis of ALS is made on the basis of standardized diagnostic criteria (either the El Escorial criteria or the Awaji criteria). In either case, neither set of criteria require the performance ofgenetic testing in order to reach/establish a diagnosis of ALS. Nor can said testing rule out a diagnosis of ALS.While genetic testing exists for genes associated with ALS, the performance of genetic testing is not commonly pursued given the absence of clinical utility testing has in the management of this syndrome. Nor is the overall clinical significance of the presence of the various genes that comprise the requested panel known.In this setting, it cannot be concluded that performance of the requested testing reflects "accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member". Furthermore, given the need for further study of the specific genes that comprise this panel, the service may also fall into the realm of being investigational. For these reasons the service would not meet Medicare criteria for coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Amyotrophic Lateral Sclerosis (ALS) Advanced genetic testing panel have not been met.Therefore, we decided that the Plan does not have to pre-approveAmyotrophic Lateral Sclerosis (ALS) Advanced genetic testing panel.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physical and occupational therapy rendered to you on September 25, 2019 and September 26, 2019.You asked the Plan to waive the copayments forthese services. You say that you were billed a $280 copayment.The Plan denied your request. The Plan says the copayments were 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 per day for Medicare-covered physical therapy and occupational therapy services. Review of the file shows that you received physical and occupational therapy on September 25, 2019 and September 26, 2019. You have been asked to pay a $40 copayment per day for these services, for a total of $80. These services fall within the Medicare-covered physical therapy and occupational therapy services 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 copayments forthe physical and occupational therapy rendered to you on September 25, 2019 and September 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan Dro 0.0015%.You asked the Plan to pre-approve Zioptan Dro 0.0015%. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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 Zioptan Dro 0.0015%.Benefits for Zioptan Dro 0.0015%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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1851,L2397) provided to the enrollee on February 28, 2019.You asked the Plan to pay forthe 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. 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 fora lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February28, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve2 joints at 2 bilateral levels of radiofrequency ablation for a total 4 joints per session, which is the allowable amount. We decided that the Plan does not have to pre-approvean additional bilateral level of radiofrequency ablation. You asked the Plan to pre-approve3 bilateral levels of RFA. You say that the requested 3 bilateral levels of RFA is medically necessary.The Plan says that the requested 3 bilateral levels of RFA does not meet criteria.We decided that the Planhas to pre-approve2 joints at 2 bilateral levels of radiofrequency ablation for a total 4 joints per session, which is the allowable amount. 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 rules also say that no more than 4 joints are allowed to be injected per session.We looked at the file and Medicare rules. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request.A request for additional information was sent to the Plan on February 26, 2020 and March 4, 2020 with no response. A request was made for the Plan to provide clarification on what levels the provider would like to be treated for the enrollee. The Plan's argument for denial is thatthe requested amount is more than the allowed amount. The Plan has not clarified if they have or would have approved the allowed amount per Medicare guidelines. They have not provided enough information to substantiate the reasoning for their denial. Therefore, we decided that the Plan has to 
pre-approve2 joints at 2 bilateral levels of radiofrequency ablation for a total 4 joints per session, which is the allowable amount. We also decided that the Plandoes not have to pre-approvean additional bilateral level of radiofrequency ablation.The Plan must follow Medicare rules. The rules say that no more than 4 joints are allowed to be injected per sessionWe looked at the file and Medicare rules. The original request was for 6 joints to be injected. Medicare covers no more than 2 thermal radiofrequency sessions in any 12-month period, involving no more than 4 joints per session, e.g., 2 bilateral levels or 4 unilateral levels. In this case, the Plan has to approve 4 joints, which is the allowed amount per session. Therefore, we decided that the Plan does not have to pre-approvean additional bilateral level of radiofrequency ablation.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says the LTACH admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. He has since been weaned from the ventilator to a tracheotomy collar. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 10, 2019.
You asked the Plan to pay for the orthoses. 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. 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 for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for observation services (99217) provided April 18, 2018.
You asked the Plan to pay for the observation care. You say that the services were submitted within a reasonable timeframe. The Plan denied your request. The Plan says claims must be submitted within 365 days of the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the observation care was not filed until July 15, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for observation services (99217) provided April 18, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for an abdominal ultrasound provided on October 7, 2019.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was applied based on the services provided and the Plan contract agreement.
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 $350 for outpatient procedures. In this instance you are being charged less than the regular copayment expectation. 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 charged for an abdominal ultrasound provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 11043 and 11046 provided on October 2, 2019.
You asked the Plan to pay for CPT codes 11043 and 11046. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 11043 is Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. We find that CPT code 11043 is not supported in the medical record. Specifically, the medical records do not document that debridement, muscle and/or fascia; first 20 sq cm or less was performed. CPT code 11043 is the primary service code and is not covered in this case. As the primary service code is not covered, CPT code 11046 cannot be paid. Based on this information, we decided that Medicare rules for coverage of CPT codes 11043 and 11046 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 11043 and 11046 provided on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora seat lift mechanism and chair (E1399).You asked the Plan to pay for the seat lift mechanism and chair. You say that you are unable to get up from a seated position because you have congestive heart failure and arthritis. You live alone, and without this device you would not be able to live an independent life and would need to reside in a nursing home.The Plan denied your request. The Plan says medical necessity has not been established for the seat lift mechanism, and the lift chair is not a covered benefit.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. In this instance, the records do not support that you have a covered diagnosis, or that the seat lift mechanism is part of your physicians planof treatment. There is no evidence in the records that you are unable to stand from a regular armchair of appropriate height. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism and chair have not been met.Therefore, we decided that the Plan does not have to pay fora seat lift mechanism and chair (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 18, 2018.
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. 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 for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 18, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for imaging services received on June 26, 2019.
You asked the Plan to waive the copayment for the services. You say that this should be paid for. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.
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 $150 copayment for advanced imaging. You have been asked to pay a $150 copayment for the services. The services fall within the advanced imaging 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 imaging services received on June 26, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the exam (G0101) you received on August 12, 2019.
You asked the Plan to pay for the exam. You say that you were told this would be covered. The Plan denied your request. The Plan says that this is not a covered service.
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. You were provided for the exam by a contracted provider. You have no control over how the provider bills the services. The file does not show that the Plan provided notice that the exam would not be covered. Under Medicare rules, this means the exam is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the exam (G0101) you received on August 12, 2019.