Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that The Plan denied your request.
The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 a semi-electric hospital bed. Our
reviewer says that a semi-electric hospital bed is not medically necessary and reasonable in this case. There is
no indication you require frequent and/or immediate body position changes, or special attachments not feasible
with a standard bed. Our physician reviewer found that your condition does not meet Medicare criteria for a
semi-electric hospital bed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve topical solution for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 topical solution for the enrollee.
Benefits for these services 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 a somatosensory study (95926) provided on August 22, 2019.You asked the Plan to pay for the somatosensory study. You say that you would like reconsideration because this service is supported by the medical record. The Plan denied your request. The Plan says the records submitted do not support the service that was billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95926 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs .We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the somatosensory study. Our reviewer says that CPT code 95926 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation to indicate that Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs was performed on August 22, 2019, therefore, this service cannot be validated.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the somatosensory study have not been met. Therefore, we decided that the Plan does not have to pay for a somatosensory study (95926) provided on August 22, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on September 19, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because this service was downcoded in error. The Plan denied your request. The Plan says the level of service for this Evaluation and Management code was reduced based on the diagnostic information.
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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the emergency department visit. Our reviewer says that the billing of CPT 99285 requires a comprehensive history, comprehensive examination and high complexity medical decision making. Our reviewer found the documentation does not note high complexity medical decision making or a high severity of symptoms. Therefore, the billing of CPT 99285 is not supported.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endosteal implant (D6010), second stage implant surgery (D6011), and an unspecified implant procedure (D6199).
You asked the Plan to pre-approve the dental services. You say that a dental implant is the best option for the enrollee. You say that the adjacent teeth # 13 and 15 are already compromised, therefore, a dental bridge would not suffice. The Plan denied your request. The Plan says the endosteal implant, second stage implant surgery, and an unspecified implant procedure are not listed as covered services.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant (D6010), second stage implant surgery (D6011), and an unspecified implant procedure (D6199).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96401) provided on October 15, 2019.
You asked the Plan to pay for the chemotherapy administration. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the administration of certolizumab pegol, code J0717, in its subcutaneous or intramuscular forms should not be billed using a chemotherapy administration code. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the chemotherapy administration. Our reviewer says that CPT code 96401 does not meet criteria for billing or reimbursement consideration. Our reviewer found per Medicare, it is inappropriate to use administration code 96401 in conjunction with Healthcare Common Procedural Coding System code J0717. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96401) provided on October 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.You asked the Plan to pre-approve the Zilretta. You say that the member has previously tried and failed to have an adequate response to Kenalog. The Plan denied your request. The Plan says the clinical records do not document that the member has tried, failed or has contraindication to the formulary alternative.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 askedour 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 Zilretta. Our reviewer says that the provided medical records do not indicate that the member has tried and failed a trial of Kenalog. Our physician reviewer found the records do not indicate that the Plan's required drug would likely be less effective or likely cause adverse effects.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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6752) and 2 pontics (D6242).
You asked the Plan to pre-approve the dental services. You say that the enrollee is on a medication which
lowers his immune system. You say that partials and implants pose higher than normal risk for infection. You
say that the enrollee would prefer a fixed bridge for teeth # 8, 9, and 10 as he does not want an appliance in the
palate due to an exaggerated gag reflex. You also say that teeth # 8 and 10 are heavily restored and would
benefit from full coverage. The Plan denied your request. The Plan says retainer crowns and pontics are not
listed as covered services.
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 dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
retainer crown (D6752) and 2 pontics (D6242).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from March 12, 2019 to July 2, 2019 billed with code S9328.
You asked the Plan to pay for the HIT services as billed. You say that this should be covered by the plan. The Plan denied your request. The Plan says Medicare does not make payment for the billed code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S9328 has a status indicator of "I", meaning that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from March 12, 2019 to July 2, 2019 billed with code S9328.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00902) provided on July 16, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim is a duplicate to another that was processed and paid to a provider in the same group and tax ID.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Specifically, this claim is a duplicate of another that was processed and paid previously. The record indicates that the provider is billing as both an individual and group. The submitted documentation does not support the billed service. Therefore, we decided that the Plan does not have to pay for anesthesia services (00902) provided on July 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam Tab.You asked the Plan to pre-approveLorazepam Tab. You say that the enrollee is stable on this medication and has experienced therapeutic results.The Plan denied your request. The Plan says Lorazepam Tab is determined to be a self-administeredPart D drug.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugrequested here isnot among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveLorazepam Tab.Benefits for Lorazepam Tabmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 18, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October
18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you feel like you were misled to think this provider was in-network. The Plan denied your request. The Plan says no prior authorization was obtained. The plan says that these services could have been provided in-network.
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 an office visit provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 9, 2019 and August 23, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says services from non-participating provider are not covered unless they are prior authorized by 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 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 psychotherapy services provided on August 9, 2019 and August 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe sclerotherapy services provided on August 29, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that compressive sclerotherapy is indicated for local small to medium symptomatic varices (3-6 mm in size), isolated incompetent perforators or recurrence of symptomatic varices after adequate surgical removal of varices.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 services. Our reviewer says that the services were not medically reasonable and necessary. Our physician reviewer found that there is inadequate documentation that there was a concerted effort at conservative treatment. The chief complaint was spider veins which is not considered a medically necessary indication for treatment.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 pay forthe sclerotherapy services provided on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the outpatient office visit. You say that this provider has experience with patients who have had ophthalmoplegia. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan has approved the 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve outpatient office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approve a referral.You asked the Planto pre-approvethe referral. You say that this dermatologist is in the SCAN program.The Plandenied your request. The Plansaysthatdiagnosis and treatment of common skin conditions is within the scope of care of a Family Practice Doctor.The Plan must follow Medicare rules. Medicare rules say that if there are nospecific 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 referral. Our reviewer says that the requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found you have a high risk of developing skin cancer, and therefore you should regularly be evaluated by an in-network dermatologist.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 referral have been met.Therefore, we decided that the Planhas to pre-approvea referral.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on February 27, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service. 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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure". We find that CPT code 95999 is not supported in the medical record. Specifically, CPT 95999 was reported for train of four testing. Train of four testing is not an unlisted procedure. There is a more appropriate code for train of four testing. Additionally, train of four testing is a bundled procedure and cannot be paid separately. 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 pay for the train of four testing (CPT 95999) provided on February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Part B injection provided on November 19, 2019.
You asked the Plan to reduce the coinsurance for the Part B injection. You say that you have previously paid $10.84 for your iron injection. You say you are not able to afford to pay this amount. 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $164.55 which is 20% of the allowed amount for the Part B injection. The allowed amount is $822.75. ($822.75 x 20% = $164.55). The Part B injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the Part B injection provided on November 19, 2019.