Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral drugs and lidocaine gel provided during an outpatient hospital stay on December 2, 2019.
You asked the Plan to pay for the oral drugs and lidocaine gel. You say that these drugs were administered by the staff and you did not realize that you had the option to administer them yourself. They were necessary for the treatment of your condition and should be covered. The Plan denied your request. The Plan says these drugs are usually self-administered and were provided while receiving outpatient services. Medicare Part B does not cover these types of drugs in the outpatient setting. Part D reimbursement must be requested in this case.
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 pay for the oral drugs and lidocaine gel provided during an outpatient hospital stay on December 2, 2019.
Benefits for the oral drugs and lidocaine gel 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries (93925).
You asked the Plan to pre-approve a duplex scan of lower extremity arteries. You say that you need this service because you have leg pain and are a gymnast. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that peripheral arterial evaluations are covered for the above indications. We looked at the file and Medicare rules. The submitted medical records do not show that you have any of the above indications. The record states that you have unspecified muscle pain. This information is not sufficient to demonstrate medical necessity. Based on this information, we decided that Medicare rules for coverage of a duplex scan of lower extremity arteries have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries (93925).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 26,
2019.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual exam and
that you were aware that you would be charged for any other service discussed outside of that. You say your
doctor brought up the other services. 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 $20
copayment for each office visit to any PCP type provider.
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services including doctor's office visits" benefit category. The record shows a diagnosis of
hypertension which was addressed in addition to the annual wellness visit.
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 office visit provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250) for teeth 6, 7, 21, 22, and 23.
You asked the Plan to pre-approve the dental services. You say that The Plan denied your request. The Plan says removal of residual tooth roots is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removal of residual tooth roots is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250) for teeth 6, 7, 21, 22, and 23.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from September 7, 2019, and September 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider from September 7, 2019, and September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone Sodium Phosphate for the enrollee.
You asked the Plan to pre-approve the drug. You say that this will be used in the treatment of the enrollee's malignant neoplasm of the lung. The Plan denied your request. The Plan says the routine costs associated with a clinical trial should be billed to Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone Sodium Phosphate for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a duplex scan of upper extremity arteries (93931) provided on September 3, 2019.
You asked the Plan to pay for the duplex scan. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says that payment is not allowed for this service because the diagnosis code is not valid for the date of service billed.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded sufficient information to indicate who ordered this test or why the diagnosis code submitted is inappropriate. Therefore, we decided that the Plan has to pay for a duplex scan of upper extremity arteries (93931) provided on September 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your diagnosis causes inflammation which is quite painful and which causes you to walk as little as possible. You say that you previously have had a heart attack and your cardiac rehab program has emphasized walking as a way to improve your health. Since developing the problem with your feet, you say that you have not been able to walk much. Your doctor recommended getting the orthotics and said that they could possibly help. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on November 14, 2019.
You asked the Plan to pay for the crown. You say that you are aware of the rules regarding coverage, but your existing crown had split. You also say that the split crown broke in half and had to be replaced. The Plan denied your request. The Plan says benefits for this service are limited to one time per sixty-month period.
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, crowns are covered only after 60 months from the date of initial placement. The record shows that you received a crown on April 24, 2018, and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown provided on November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
You asked the Plan to preapprove a pneumatic compression device. You say that you would like this device to use at home to treat edema. The Plan denied your request. The Plan says this device is used to prevent blood clots in the legs, and is noncovered by Medicare.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroscopy services coded 2999 provided on October 10,
2019.
You asked the Plan to pay for the arthroscopy services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are non-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 29999 is unlisted procedure, arthroscopy.
We find that CPT code 29999 is not supported in the medical record. Specifically, this service is not eligible for
reimbursement. on Line 1 of the claim, code 29880 was billed and processed by the plan. Based on this
information, we decided that Medicare rules for coverage of the arthroscopy services have not been met.
Therefore, we decided that the Plan does not have to pay for the arthroscopy services coded 2999 provided on
October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate cancer screening you had on July 18, 2019.
You asked the Plan to pay for the screening. You say that this should be paid more than once every 12 months. The Plan denied your request. The Plan says this service is covered once every 12 months.
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 $0 copayment for a prostate cancer screening once every 12 months. Review of the file shows that you had a prostate cancer screening on July 18, 2019. The records also show that you had a covered prostate cancer screening on October 29, 2018. This means that the requested screening was provided less than 12 months from you last covered exam, which exceeds the benefit limit. You are not eligible for another covered screening until October 29, 2019. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the prostate cancer screening you had on July 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 1, 2019 to September 7, 2019.
You asked the Plan to pay for the SNF services. You say that since the health center is considered out of network with the health plan, no prior authorization is required before the delivery of skilled services. The Plan denied your request. The Plan says the SNF services were not medically necessary. Services could have been provided at a lower level of 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 1, 2019 to September 7, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve consultation services for proton beam
therapy evaluation.
You asked the Plan to pre-approve the proton beam therapy evaluation services. You say that you have a
moderately aggressive prostate cancer and your options are to either remove the prostate or have proton beam
therapy. You say that you have received reports that proton therapy is effective and you needs this treatment as
soon as possible. The Plan denied your request. The Plan says that proton beam therapy is not a medically
necessary treatment for cancer of the prostate.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 proton beam therapy evaluation
services. Our reviewer says that proton beam therapy evaluation services are considered medically reasonable
and necessary in this case. Our physician reviewer found photon and proton external beam radiation therapy
(ERBT) are both effective at achieving highly conformal radiotherapy with acceptable and similar biochemical
control. The provider panel sees no benefit or detriment for photon
therapy. There is however an ongoing trial to compare photon and proton therapy.
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 proton beam therapy evaluation services have been met. Therefore, we
decided that the Plan has to pre-approve consultation services for proton beam
therapy evaluation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 4, 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. 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 knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan for the enrollee.
You asked the Plan to pre-approve Xifaxan. You say that this is medically necessary. 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-approve Xifaxan for the enrollee.
Benefits for Xifaxan 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 pre-approve varicose vein treatment.
You asked the Plan to pre-approve the varicose vein. The Plan denied your request. The Plan says the enrollee 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve varicose vein treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for a knee replacement procedure.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the admission is medically necessary. The Plan denied your request. The Plan says the procedure can be performed in an outpatient setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there was no documentation provided necessitating an inpatient hospital admission for the procedure. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for a knee replacement procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegingival irrigation (D4921) for all 4 quadrants.You asked the Plan to pre-approvethe gingival irrigation. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested gingival irrigation is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvegingival irrigation (D4921) for all 4 quadrants.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.