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

We decided that the Plan does not have to pay for cardiovascular monitoring services provided on November
18, 2019.
You asked the Plan to pay for the cardiovascular monitoring services. The Plan denied your request. The Plan
says non-emergent, non-urgent services with out-of-network providers require 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 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 cardiovascular monitoring services provided on November 18,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 18, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services. 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 physician's services provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.You asked the Plan to pay for foot orthotics. You say that the services should be covered.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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition.Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve26 additional doses of Privigen injection, 500 mg, to be given every 4 weeks.You asked the Plan to pre-approve26 additional doses of Privigen. You say that you have an autoimmune disorder. You say that it has caused you to lose the ability to walk.The Plan denied your request. The Plan says the additional 26 doses are not medically necessary. The Plan says that more than 13 doses of this medication, given every 4 weeks was considered investigational based on a lack of substantiation in the medical literature.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 26 additional doses of Privigen. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the documentation does not support the treatment course requested. The additional 26 doses are not medically necessary and are considered to be investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 26 additional doses of Privigen have not beenmet.Therefore, we decided that the Plan does not have to pre-approve26 additional doses of Privigen injection, 500 mg, to be given every 4 weeks.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the skilled nursing facility care. You say that continued inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage of continued inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 the skilled nursing facility care. Our reviewer says that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the medical records do not indicate that you have a need for daily skilled therapy services. Additionally, you do not require necessary services on an inpatient basis, in a skilled nursing facility. Care in the home or in an assisted living facility with home health services appears to be appropriate. 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 skilled nursing facility care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on September 19, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 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 80307 is drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. The CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on September 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 20, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that the copayment should have been paid in full by the Plan. 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 a $50 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay a $50 copayment for the ultrasound. The ultrasound 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 waive the copayment for the ultrasound provided on February 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you do not see the patient. You say that no prior authorization should be require.The Plan denied your request. The Plan says no prior authorization was obtained.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. Wefound no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forlab work provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laminectomy, facetectomy and foraminotomy (63047).
You asked the Plan to pre-approve the laminectomy, facetectomy and foraminotomy. You say that this
procedure is medically necessary for the treatment of your condition. The Plan denied your request. The Plan
says you are morbidly obese, which represents significant risk and concern for improper healing postprocedure.
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 the laminectomy, facetectomy and
foraminotomy. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the MRI does not show severe neurologic compression
and there is no correlation with the physical exam.
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 laminectomy, facetectomy and foraminotomy have not been met. Therefore,
we decided that the Plan does not have to pre-approve a laminectomy, facetectomy and foraminotomy (63047).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultra-lightweight wheelchair (CPT Code K0005).
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the wheelchair will make better quality of life for you and you cannot get around on your own. 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 durable medical equipment (DME) have not been met. Your letter indicates that you have a wheelchair that you have used since your stroke in 2017 that is broken. This was not indicated in the first request. It is not known what is wrong with this wheelchair and if it could be fixed instead of replaced. We also do not know how old it is or what kind it is. You currently push your wheelchair with your feet.
The notes say you need an ultra-lightweight wheelchair and that other wheelchairs like a standard or lightweight wheelchair will not work for you. We know that you can push the wheelchair you have right now but do not know what kind it is. There are still no notes that you have actually tried the different types of wheelchairs. We do not know that you can push better in the ultra-lightweight wheelchair. Therefore, we decided that the Plan does not have to pre-approve ultra-lightweight wheelchair (CPT Code K0005).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton treatment (77523).
You asked the Plan to pre-approve proton treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 proton treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there is no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve proton treatment (77523).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic mammography and
ultrasound you received on June 5, 2019.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible
for the copayment.
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 $25
copayment for outpatient hospital services.
Review of the file shows that you had a diagnostic mammography and an ultrasound on June 5, 2019. You
have been asked to pay a $25 copayment for each the services, totaling $50. The services fall within the
outpatient hospital 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 for the
diagnostic mammography and ultrasound you received on June 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 30.
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says the crown is not medically necessary.
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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the requested dental service is not medically necessary. Our physician reviewer found The radiograph submitted was not of diagnostic quality. Based on this lack of documentation it could not be determined if the criteria for coverage for a crown for tooth #30 have been satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 30.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine Tablets, 10MG.
You asked the Plan to pre-approve Cyclobenzaprine. You say that the drug is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine Tablets, 10MG.
Benefits for Cyclobenzaprine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on October 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on October 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography with Doppler complete.
You asked the Plan to pre-approve the services. You say that you have heart palpitations, irregular heartbeats, and lightheadedness. The Plan denied your request. The Plan says no indication was provided for this.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided, the enrollee has brief palpitations surrounding a flu that have improved, isolated PVC on electrocardiography and a normal cardiovascular physical exam. In this circumstance, since the symptoms were very brief, improved, and with only isolated ectopy, and a normal cardiac exam, the documentation does not support the medical necessity for an echocardiogram. Current guidelines endorsed by several national organizations also do not consider an echocardiogram appropriate for "Patients who have isolated APC or PVC without other evidence of heart disease". Coverage criteria are not met since the test exceeds the enrollee's medical need 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiography with Doppler complete.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care you received on April 22, 2019, and April 23, 2019.
You asked the Plan to waive the copayment. You say that the hospital you went to was not equipped for the surgery you needed. 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 a $90 copayment for emergency services. Review of the file shows that you were provided emergency services on April 22, 2019, and April 23, 2019. You have been asked to pay a $90 copayment for the services. The services fall within the emergency 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 waive the copayment for the emergency care you received on April 22, 2019, and April 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran MRI provided on December 13, 2019.You asked the Plan to waive the copayment foranMRI. You say that the test was no good and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $125 copayment for advanced imaging services. You have been asked to pay a $125 copayment for an MRI. An MRI 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 waive the copayment foran MRI provided on December 13, 2019.