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

We decided that the Plan does not have to pre-approve the pulmonology services to be provided by an out of network provider.
You asked the Plan to pre-approve the OON pulmonology services. You say that you followed up with two of the pulmonary specialists that the Plan recommended and one was not accepting new patients and the other did not respond for a month before saying he does not see patients. You feel that since you had to wait a month based on incorrect referrals, the Plan should approve the OON care. The Plan denied your request. The Plan says on appeal, it was found that there are two providers accepting new patients at the in-network tertiary office.
You have made an appointment for February 13, 2020 and the in-network provider has availability as early as January 27 or 28. Since there are network providers able to treat your condition, there is no need for OON care.
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 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. 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 the pulmonology services to be provided by the  out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided on July 14, 2018 to July 17, 2018.
You asked the Plan to pay for subsequent hospital care. You say that these services were provided out of absolute medical necessity and in good faith of payment. The Plan denied your request. The Plan says the claim was billed with either an invalid or missing modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. This claim was billed with either an invalid or missing modifier. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care provided on July 14, 2018 to July 17, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the Medicare criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that CGM coverage requires that the enrollee test blood sugar four or more times per day and perform three or more insulin injections per day. In this case, the documentation shows that testing is occurring once per day and there is no clear documentation of the amount of insulin injections required. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent 300 MG/2 ML Syringe.
You asked the Plan to pre-approve Dupixent 300 MG/2 ML Syringe. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Dupixent 300 MG/2 ML Syringe.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora hospital outpatient clinic visit provided on May 3, 2019.You asked the Plan to pay forthe hospital outpatient clinic visit.The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 thiscase is not a network provider with the Plan. The Plan did not pre-approve the hospital outpatient clinic visit. 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 fora hospital outpatient clinic visit providedon May 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a knee brace (L1830LT) provided on August 30, 2019.
You asked the Plan to waive the coinsurance for a knee brace. You say that you are disputing the $16.24
coinsurance amount. The Plan denied your request. The Plan says Durable Medical Equipment (DME) has a
20% coinsurance. The Plan also says the facility will not accept a return on the knee brace and
therefore, the initial applied coinsurance amount has been upheld.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Durable Medical Equipment (DME).
You have been asked to pay a 20% coinsurance for a knee brace. This service falls within the Durable Medical
Equipment (DME) benefit category. The allowable amount of $81.22 x 20% = $16.24. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance for a knee brace (L1830LT) provided on August 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 55 mile routine transportation trips.
You asked the Plan to pre-approve 55 mile routine transportation trips. You say that you need five additional miles to attend your doctor appointments. The Plan denied your request. The Plan says your benefit only covers transportation up to 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation trips when they do not exceed 50 miles. We looked at your request, the records in the case file, and the rules. The trips you are requesting exceed 50 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation trips have not been met. Therefore, we decided that the Plan does not have to pre-approve 55 mile routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve marinol 10mg capsules.
You asked the Plan to pre-approve the marinol capsules. You say that this is a necessary medication. The Plan denied your request. The Plan says the oral drug is not covered by Medicare 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 marinol 10mg capsules.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a one-month supply allowance for a therapeutic continuous glucose
monitor (K0553) for date of service March 14, 2019.
You asked the Plan to pay for a one-month supply allowance for a therapeutic continuous glucose monitor.
You say that you are billing according to Medicare guidelines. The Plan denied your request. The Plan says
that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific
supplies, or proof of delivery.
The Plan must follow Medicare rules. The rules state that a supplier does not have to deliver supplies used with
a therapeutic CGM every month in order to bill code K0553 every month. In order to bill code K0553, the
supplier must have previously delivered quantities of supplies that are sufficient to last for one (1) full month
following the DOS on the claim. No more than 1 unit of service (UOS) for code K0553 per month is billable at
a time. Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity of BGM
testing supplies at a time.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a one-month supply allowance for therapeutic continuous glucose monitor have been met.
Specifically, the supplies in this case were delivered in a 90-day supply for K0553, which the Proof of Delivery
supports. The supplier is only billing one unit of K0553 at a time for supplies that are sufficient for one full
month following the DOS on the claim. The supplier in this case is billing in accordance to Medicare rules for
continuous glucose monitoring supplies. Therefore, we decided that the Plan has to pay for a one-month supply
allowance for a therapeutic continuous glucose monitor (K0553) for date of service March 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Victoza injections 18MG/3ML.
You asked the Plan to pre-approve Victoza injections. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says Victoza is not covered under the enrollee's Part B benefit.
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 Victoza injections
18MG/3ML.
Benefits for Victoza injections 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 services provided to the enrollee from June 25, 2019 to June 27, 2019 and billed under codes 82947 and 84450.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare guidelines HCPCS codes 82947 and 84450 are identified as part of another procedure, 80053, coded on the same day without an appropriate modifier. Therefore, based on the Medicare guidelines, this claim cannot be paid as billed. The Plan states a corrected claim would be reviewed if submitted.
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, codes 82947 and 84450 cannot be paid separately due to their bundled relationship with code 80053. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee from June 25, 2019 to June 27, 2019 and billed under codes 82947 and 84450.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that you were prescribed the stockings and they should be covered. The Plan denied your request. The Plan says gradient compression stockings A6533 are non-covered under the surgical dressing benefit per Medicare rules because it does not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from May 24, 2019 to August 12, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from May 24, 2019 to August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on June 5, 2019 to
June 10, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that you were unaware that the enrollee
was covered under this plan and request review of the medical records to approve this 5 day inpatient detox
admission. The Plan denied your request. The Plan says enrollees must receive their medical services from an
in-network provider. The plan says that non-emergent services with non-contracted providers require priorauthorization
prior to services being rendered.
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 inpatient hospital services provided on June 5,
2019 to June 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The
Plan denied your request. The Plan says the requested Keytruda is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 Keytruda. Our reviewer says that the
requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is diagnosed with
stage IV cholangiocarcinoma, tumor PDL-1 was 50-60% positive. Pembrolizumab (Keytruda) is not FDA
approved or compendia or literature supported in cholangiocarcionoma. Only generally approved in cancers
with MMR deficient tumors.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided to the enrollee on March 21, 2019 and billed under code 01922.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Plan states that code 01922-AA, QS (25 units) is not supported by the records. The documentation submitted did not include documentation of anesthesia notes with start and stop time for the billed service. The submitted vital signs record only indicated that propofol was administered at 12:15 pm and stopped at 12:25 pm, however the time documented does not support the 25 units billed. In addition, the notes did not include the time in which the anesthetist entered the room or when the enrollee was placed in post-operative care; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 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 and when required provide specific records to support the timed services billed. In this case, code 01922 has a time documentation requirement. There are insufficient records to support the billing of this code. Therefore, we decided that the Plan does not have to pay for diagnostic services provided to the enrollee on March 21, 2019 and billed under code 01922.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for a home visit provided on July 3, 2019.
You asked the Plan to pay for the physician's services for a home visit. You say that The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. 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 physician's services for a home visit provided on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960)
You asked the Plan to pay for the SEWHO. You say that your exam notes are the result of an initial phone
consultation between a physician and the enrollee . This is not a telehealth visit as described by CMS so there is
no originating site. The Plan denied your request. The Plan says there is insufficient documentation to
corroborate the service so that the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the shoulder, elbow, wrist,
hand orthosis (SEWHO) (L3960)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on June 28, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. 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 a hospital outpatient clinic visit provided on June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on April 4, 2019 and billed under code A9579.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says code A9579 (8 Units) remains not supported. The billing guidelines state code A9579 represents an injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml. The submitted documentation indicated that injection of gadobutrol (GADAVIST) was administered on the billed date of service. The Plan states a more appropriate code to bill for this service would have been code A9585. The Plan states additional information was requested from the provider but was not received.
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, code A9579 cannot be verified for the date of service billed. The Plan has instructed the correct code to be billed and requested either additional information or a corrected claim to resolve this issue. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for injection services provided to the enrollee on April 4, 2019 and billed under code A9579.