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

We decided that the Plan does not have to pre-approve Travatan Z drops 0.004% for the enrollee.
You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered medication.
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 Travatan Z drops 0.004% for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) provided on October 15, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the place of service billed is inappropriate for this 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. We find that CPT code L0648 is not supported in the record. Specifically, reimbursement of DME items is limited to a place of service that qualifies as the member's home. This claim was submitted with place of service, "11," or office. This is not a reimbursable place of service for DME claims. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) provided on October 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of the Superion Interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary as the enrollee has lumbar spinal stenosis. The Plan denied your request. The Plan says overall, there is a lack of evidence to support that interspinous spacer devices are as safe and effective as surgical decompression and there are concerns about higher rates of re-operation.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found this procedure is still considered experimental/investigational. Therefore, this service is not medically reasonable or necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the insertion of the Superion Interspinous stabilization device (22869, 22870).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 74263) provided to the enrollee on July 8, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered 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 74263 is "Computed tomographic (CT) colonography, screening, including image post-processing." We find that CPT code 74263 is not supported in the medical record. Specifically, this code has a status code of "N", which means that it is not covered. 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 radiology services (CPT 74263) provided to the enrollee on July 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from June 18, 2019 through June 19, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctorexpects 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 pay for 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 the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation 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 hospitalcare have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from June 18, 2019 through June 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the UTX Reflect testing rendered to the enrollee on August 9, 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 the testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee had pain with urination and was diagnosed with a urinary tract infection. The role of UTX Reflect testing in the management of urinary tract infection has not been clearly established. The documentation does not support that UTX Reflect testing was medically reasonable and necessary for the enrollee in this case. It has not been established how this testing was likely to impact the management of this enrollee. We looked at this physician's review, the file, and Medicare rules. 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 UTX Reflect testing rendered to the enrollee on August 9, 2019.
The Plan references NCD 190.12 and MolDx rules in their determination; however, this NCD and the MolDx program are not binding and were not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the skin biopsy and office visit provided on August 14, 2019 and August 27, 2019.
You asked the Plan to waive the copayments for the skin biopsy and office visit. You say that you had all of your copayments paid before this. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each physician specialist visit for Medicare-covered services. Covered services include medically necessary medical care or surgery services furnished in a physician's office. You have been asked to pay a $40 copayment for the skin biopsy provided on August 14, 2019. You have also been asked to pay $29.84, which is less than the standard $40 copayment for the office visit provided on August 27, 2019 because you met your out-of-pocket maximum. The skin biopsy and office visit fall within the "Physician/Practitioner services, including doctor's office visits" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the skin biopsy and office visit provided on August 14, 2019 and August 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMs for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has hypertension, hyperlipidemia, coronary artery disease, diabetes, mitral regurgitation, pacemaker placement and congestive failure with variable ejection fraction (35-60 percent) requiring hospitalization. In this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. The efficacy of the CardioMEMs is uncertain and the services are considered experimental/investigational in nature and not medically necessary. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve CardioMEMs for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on August 23, 2019.You asked the Plan to pay forthe orthosis and sleeve. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and managementservice. The Plan states the review of claims history for this member, and a review of the submitted documentation does not containevidence of a prior Telemedicine or Telehealth service with the ordering physician as requiredper CMS guidelines.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 forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urology services (CPT 51700 and 51792) provided to the enrollee on June 26, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 51700 and 51792 remains 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 the denied code is: CPT 51700: Bladder irrigation, simple, lavage and/or instillation CPT 51792: Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time) 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 at issue in this case were not coded correctly. Our physician reviewer found while fluid was instilled into the balder during the CMG/urodynamic testing, there is no evidence that a separate or purposeful bladder irrigation or lavage was performed. There is no evidence that BCR testing was performed. Therefore, the billing of CPT 51700 and CPT 51792 are 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 urology services (CPT 51700 and 51792) provided to the enrollee on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110), electrical stimulation (G0283), application of hot or cold packs (97010), and manual therapy (97140) provided by a chiropractor on August 21, 2019.
You asked the Plan to pay for therapeutic exercises, electrical stimulation, application of hot or cold packs, and manual therapy. You say that this should be reprocessed. The Plan denied your request. The Plan says these services are not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110), electrical stimulation (G0283), application of hot or cold packs (97010), and manual therapy (97140) provided by a chiropractor on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on May 31, 2019.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthosis and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthosis and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthosis and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on August 22, 2019.You asked the Plan to waive the deductible for the office visit. You say that you were informed the visit would be covered with a $40 copayment. You say that you were not informed the provider was out-of-network.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Out-of-network services are not excluded from the deductible.The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on August 22, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 29, 2018 by the out of network provider.
You asked the Plan to pay for these out-of-network services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 office visit provided on January 29, 2018 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forshoulder elbow wrist hand orthosis (L3916) provided to the enrollee on June 7, 2019.You asked the Plan to pay forthe orthosis. You say that the durable medical equipment is medically necessary.The Plandenied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not containevidence of a prior Telemedicine or Telehealth service with the ordering physician as requiredper CMS guidelines.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 forshoulder elbow wrist hand orthosis (L3916) provided to the enrollee on June 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a general health panel received on April 5, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this claim line is being disallowed because the services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by Medicare. You have requested payment for a GHP, billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, the Plan does not have to pay for the GHP billed under code 80050. Therefore, we decided that the Plan does not have to pay for a general health panel received on April 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pulse oximeter (E0445) provided from August 5, 2019 through September 4, 2019.
You asked the Plan to pay for the pulse oximeter. You say that you have had breathing problems for the past three years and the machine really helps you. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pulse oximeter have not been met. This is an item that is not covered by Medicare. The requested item cannot be approved. You do have a benefit for Over the Counter Benefits. These devices are available over the counter for about $50 and your benefit is for payment of up to $30 quarterly for over the counter items. Therefore, we decided that the Plan does not have to pay for pulse oximeter (E0445) provided from August 5, 2019 through September 4, 2019.