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

We decided that the Plan does not have to pay for a portable oxygen concentrator provided on December 5, 2019.
You asked the Plan to pay for the portable oxygen concentrator. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 and the referring provider in this case are not network providers with the Plan. The Plan did not pre-approve the portable oxygen concentrator. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the services are available in-network and are not emergent or urgent.
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 the requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on January 30, 2020.
You asked the Plan to pay for periapical x-rays. You say that you told your dentist you only wanted covered services. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on January 30, 2020.
Your complaint about your dentist provided non-covered services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic parenteral drugs, two or more
administrations, different medications (D9612).
You asked the Plan to pre-approve the dental services. You say that the medications are required while under
anesthesia for oral surgery. You cannot afford to pay for the medications along with having to pay for an upper
denture and 50% of the surgery itself. The Plan denied your request. The Plan says this service is not a covered
benefit.
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. Services not listed as a
covered service is not covered by the plan.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
therapeutic parenteral drugs, two or more administrations, different medications (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral exam received on December 5, 2019.
You asked the Plan to pay for the exam. You say that you are allowed three cleanings per year, including periodontal maintenance cleanings. The Plan denied your request. The Plan says the exam was denied due to it exceeding frequency limitations.
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 two oral exams per year. The file shows that you received oral exams on May 30, 2019 and October 2, 2019. Based on this information, we decided that the Plan's rules for coverage of the exam have not been met. Therefore, we decided that the Plan does not have to pay for an oral exam received on December 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee is covered for up to 24 one-way transportation trips per year. The Plan says that the enrollee has used 23 of the 24 allotted trips and no additional trips will be approved.
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 a maximum of 24 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. The file shows that the enrollee has used 23 of the 24 allowed trips for the 2020 benefit year. The enrollee has one trip remaining and then the enrollee will have exhausted the transportation benefit for the 2020 benefit year. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs purchased outside of the United States on December 8, 2019.
You asked the Plan to pay for these services. You say that you would like the services reimbursed. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that drugs sold outside of the United States are excluded from coverage. We looked at the file and Medicare rules. The services at issue are drugs purchased outside of the United States. These services are excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pay for drugs purchased outside of the United States on December 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) with interpretation rendered on October 11, 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 procedure code 93010 is not supported.
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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of interpretation of an EKG. 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 electrocardiogram (EKG) with interpretation rendered on October 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on December 19, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because the images were for the wrong region of your body. 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 $250 copayment for diagnostic radiology services. You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on December 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz (Hyaluronan or derivative). You asked the Plan to pre-approve the Supartz. The Plan denied your request. The Plan says documentation supporting the medical necessity for a step therapy exception was not received. The Plan also says that the information submitted does not meet the Plan's medical necessity guidelines for coverage. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Supartz. Our reviewer says that the Supartz is not medically necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires these be trialed first. Our reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. Our reviewer also found that without the support of the documentation, Supartz is not approved as step criteria is not met. 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 Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz (Hyaluronan or derivative).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the stockings for management of his lymphedema. The Plan denied your request. The Plan says these compression stockings are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
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, L2810) provided to the enrollee on September 12, 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 rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397, L2810) provided to the enrollee on September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) (CPT Code 95885), nerve conduction studies; 3-4 studies (CPT Code 95908), electroencephalogram (EEG) during non-intracranial surgery (e.g., carotid surgery) (CPT Code 95955) provided to the enrollee on July 11, 2019. You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 physician reviewer found based on the documentation provided, it is my opinion that the health plan's denial should be upheld. EEG monitoring during surgery is not the same as a diagnostic EEG performed during surgery. There is no evidence that a diagnostic EEG was performed during non-intracranial surgery. Therefore, the billing of CPT 95955 is not supported. Pedicle screw stimulation is a form of EMG monitoring, not a nerve conduction study. There is no evidence that nerve conduction studies were performed. Therefore, the billing of 95908 is not supported. EMG monitoring during surgery is not the same as a diagnostic EMG performed in conjunction with nerve conduction studies. There is no evidence that nerve conduction studies were performed. Therefore, the billing of CPT 95885 is not supported. 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 for needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) (CPT Code 95885), nerve conduction studies; 3-4 studies (CPT Code 95908), electroencephalogram (EEG) during non-intracranial surgery (e.g., carotid surgery) (CPT Code 95955) provided to the enrollee on July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care services coded 99220 provided on September 4, 2019. You asked the Plan to pay for the initial observation care 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 not supported by the documentation. 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 99220 is initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: 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 problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99220 is not supported in the medical record. Specifically, this code should only be used for the care rendered by the ordering physician on the date of the enrollee's observation services began. An initial observation care code has already been billed and processed by the plan. Based on this information, we decided that Medicare rules for coverage of the initial observation care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial observation care services coded 99220 provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on August 16, 2018. You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on August 16, 2018. The total allowed amount is $4,720.84 and 20% of that is $944.17. You have been asked to pay the total coinsurance amount of $944.17 for Medicare Part B drugs. Medicare Part B drugs fall 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 waive the coinsurance for Medicare Part B drugs provided on August 16, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. You asked the Plan to pre-approve the compression stockings. You say that your doctor says you require the stockings for management of your lymphedema. The Plan denied your request. The Plan says are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1832, L2397) provided to the enrollee on October 24, 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 enrollee has received the same supplies within the 5-year RUL. The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on October 30, 2019. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue.  Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1832, L2397) provided to the enrollee on October 24, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tildrakizumab (Ilumya). You asked the Plan to pre-approve Ilumya. You say that the enrollee does not have arthritis, only a crisis. The enrollee has tried and failed topical treatment. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Remicade or Inflectra; and Stelara. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ilumya. Our physician reviewer found that the Plan requires prior trial and failure of either Remicade or Inflectra; and Stelara, prior to approval of Ilumya. The documentation does not support that the enrollee has had trial of Remicade, Inflectra, or Stelara. The documentation does not state why the alternatives required by the Plan would not be as effective for the enrollee, or would have adverse effects for the enrollee. Therefore, the requested drug is not medically reasonable and necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve tildrakizumab (Ilumya).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 11, 2019. You asked the Plan to pay for the orthosis. 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 lumbar-sacral orthosis (L0650) provided to the enrollee on December 11, 2019.