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

We decided that the Plan does not have to pay forchemotherapy administration (96413, 96417, and 96375) provided on July 29, 2019.You asked the Plan to pay forchemotherapy administration. You say that these services are required as part of chemotherapy treatment.The Plan denied your request. The Plan says these codes are not supported by the medical records.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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug; 96417 is chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure) ;and 96375 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure).We find that CPT codes96413, 96417, and 96375 arenot supported in the medical record. Specifically, codes 96413 and 96417 are time-based codes. The record does not document the time spent on these services. Because the primary code 96413 is denied, 96375 remains denied as well. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met.Therefore, we decided that the Plan does not have to pay forchemotherapy administration (96413, 96417, and 96375) provided on July 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided by the facility from June 18, 2019 to June 25, 2019.
You asked the Plan to pay for home health care services. You say that you need these services. The Plan denied your request. The Plan says services from providers that do not participate in Medicare are not covered.
The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met. The provider you received these services from does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health care services provided by the facility from June 18, 2019 to June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor with a segmental pneumatic appliance to be provided to the enrolleebeginning November 12, 2019.You asked the Plan to pre-approvethe DME. 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 DME have not been met.Therefore, we decided that the Plan does not have to pre-approvepneumatic compressor with a segmental pneumatic appliance to be provided to the enrollee beginning November 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Fentanyl patch for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee's pain has responded well to this medication.The Plan denied your request. The Plan says that this is not covered under Part B.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-approvethe Fentanyl patch for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel One for the enrollee.
You asked the Plan to pre-approve these services. You say that you do not use orthovisc or monovisc. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the left knee. The records do not show that he has tried and failed the Plan's required drugs of orthovisc and monovisc. The records do not show that the required drugs would be less effective or contraindicated; therefore, Gel One is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Gel One for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a Group 2 powered pressure-reducing air mattress.
You asked the Plan to pre-approve continued use of a Group 2 powered pressure-reducing air mattress. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that continued use of a group 2 support surface is covered until the ulcer is healed. We looked at the file and Medicare rules. The file indicates your wound has healed. Based on this information, we decided that Medicare rules for coverage of continued use of a Group 2 powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a Group 2 powered pressure-reducing air mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewing x-ray (D0274), and the intraoral x-ray (D0220) provided on July 8, 2019.You asked the Plan to pay forthe dental services. You say that you are a contracted provider with the enrollee's Plan.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are not covered.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, dental services are not covered when they are received out of network. The record shows that the provider's contract, specific to the enrollee's network, termed on May 31, 2018. Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewing x-ray (D0274), and the intraoral x-ray (D0220) provided on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forblood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), normal, low and high calibrator solution / chips (CPT Code A4256) and replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each (CPT Code A4235) provided to the enrollee from August 10, 2019 through October 29, 2019.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the records do not support the services. 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 DME have not been met. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay forblood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), normal, low and high calibrator solution / chips (CPT Code A4256) and replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each (CPT Code A4235) provided to the enrollee from August 10, 2019 through October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each (CPT Code A4357) and urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each (CPT Code A4358) provided to the enrollee on September 5, 2019.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says this service is not approved for coverage.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 DME have not been met. Review of the available clinical case notes and records presented for an appeal of code codes A4358, urinary drainage bag, and A4357, bedside drainage bag, for date of service September 5, 2019, has been completed.  After reassessing the entire situation, the result is that the initial denial is upheld. The member received catheter supplies on September 5, 2019. The current Physician Fee Schedule does not price the requested code as it is statutorily excluded.  The service codes A4358 and A4357 are excluded by Medicare per the National Correct Coding Initiative (CCI) policy and therefore not payable by Medicare. This is a billing issue.Therefore, we decided that the Plan does not have to pay forbedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each (CPT Code A4357) and urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each (CPT Code A4358) provided to the enrollee on September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the special stain including interpretation and report and tissue exam by pathologist provided on August 21, 2019.You asked the Plan to pay forthe laboratory services. You say that you provided this service to the enrollee with the expectations that all authorizations, if necessary, were obtained by the providers sending the enrollee to you. You also say that your doctors provided these services to the enrollee in good faith.The Plan denied yourrequest. The Plan says services provided by non-participating providers are not covered unless they are authorized by the Plan before the services are provided. The Plan also says they verified that both the rendering and referring providers are non-contracted.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe special stain including interpretation and report and tissue exam by pathologist provided on August 21, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 30, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says The Plan requires utilization of network providers when possible and available and requires authorization for certain services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 subsequent nursing facility care provided on July 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transdermal scopolamine.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has tried and failed other
drugs. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because
this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D
prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 transdermal scopolamine.
Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on September 30, 2019.
You asked the Plan to pay for the eyeglasses. You say that you are appealing in the hope that the plan would consider at least covering some or all of the cost of these items. The Plan denied your request. The Plan says the maximum benefit was allowed for the claim.
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 any amount over the allowed benefit amount of $175 towards the purchase of eyeglasses or contact lenses. You have been asked to pay $360. The provider billed $535 for the services. There is a $175 benefit every 2 years towards the purchase of eyeglasses or contact lenses and the plan paid the full benefit allowance. ($535-$175=$360). You are responsible for any balance over the benefit amount for the eyeglasses. The eyeglasses fall within the Vision Care 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 pay for the eyeglasses purchased on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral (CPT Code 0207T) provided by a non-contracted provider on June 18, 2019.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this service is not covered by Medicare.
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 services have not been met. This service not covered by the Plan or Medicare. Therefore, we decided that the Plan does not have to pay for evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral (CPT Code 0207T) provided by a non-contracted provider on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit and hearing test provided on July 11, 2019.
You asked the Plan to waive the copayments for the office visit and hearing test. You submitted your bill for review. You say that you weren't told about additional charges. The Plan denied your request. The Plan says the copayments 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 $35 copayment for a specialist at an in-network specialist's office and a $10 copayment for other outpatient diagnostic tests at an in-network provider. You have been asked to pay a $35 copayment for the office visit and a $10 copayment for the hearing test. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The hearing test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 for the office visit and hearing test provided on July 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on October 8, 2019, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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 to the enrollee on October 8, 2019, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the CT scan provided on August 21, 2019.
You asked the Plan to reduce the copayment for the CT scan. You say that you should not be responsible for this bill. You say you were told there would be a $35 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each in-network Medicare-covered advanced imaging service (not including x-rays). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $225 copayment for the CT scan.
You have been asked to pay a $164.26 copayment for the CT scan. The CT scan falls 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 reduce the copayment for the CT scan provided on August 21, 2019.
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 preapproveapneumatic compression device. You say that the enrollee requires the 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 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 preapprovea pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your request. The Plan says that there was no evidence that the enrollee has tried and failed a trial of Orthovisc and Monovisc.
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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.