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

We decided that the Plan does not have to pay for educational supplies (99071) provided on December 20,
2019.
You asked the Plan to pay for the educational supplies. You say that you would like reconsideration because
the denial for these services is inappropriate. The Plan denied your request. The Plan says CPT code 99071 is
included in the payment of the other services performed on the same date of service, for the same patient, and
by the same provider and is not separately reimbursable.
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 99071 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 99071 has a status indicator of B. This means that payment for CPT code 99071 is always bundled into
the payment for other services. Based on this information, we decided that Medicare rules for coverage of the
educational supplies have not been met. Therefore, we decided that the Plan does not have to pay for
educational supplies (99071) provided on December 20, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided September 18, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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 topay 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 servicesat 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 September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 10, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses purchased on January 2, 2020.
You asked the Plan to pay for the vision services. You say that if you had been given the correct information
you would have cancelled the order and then purchased the eyeglasses from an outside provider. The Plan
denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when enrollee's must receive their vision services from an in-network
provider.
We looked at the file and the Plan's rules. Vision services provided by an out of network provider is not
covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not
been met. Therefore, we decided that the Plan does not have to pay for the frames and lenses purchased on
January 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea positron emission tomography (PET) scan of the brain (78608).You asked the Plan to pre-approvea PET scan of the brain. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 a PET scan of the brain. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found review of the records show no neurological abnormality with the exception of ataxia. The records submitted do not show any evidence of computed tomography (CT) of the brain to evaluate for metastatic disease of the brain. In addition, there is no mention of consideration of "Open magnetic resonance imaging (MRI)" which is an exam commonly administered to patients with severe claustrophobia in whom general anesthesia is not desired or is contraindicated. The request for PET/CT of the brain has been apparently made to rule out metastatic disease. As there are no mental status changes and a negative neurological exam the request is considered medically unnecessary without further supporting documentation.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 PET scan of the brain have not been met.Therefore, we decided that the Plan does not have to pre-approvea positron emission tomography (PET) scan of the brain (78608).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly moderate to maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear that you would be able to fully benefit and/or participate in an IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for home health care provided from October 25, 2019 through November 6, 2019.You asked the Plan to reduce the cost share for the home health care. You say that the provider was listed as out-of-network but they are in-network.The Plan denied your request. The Plan says the cost share 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 combined in and out-of-network deductible is $500. This is the amount you have to pay out-of-pocket before the Plan will pay its share for your Medicare Part A and Part B covered services. Out-of-network home health services aren't excluded from the deductible. Your contract with the Plan also says that you must pay 8% of the cost for each out-of-network, Medicare-covered home health visit.The item or service you asked the Plan to waive the cost share for falls within the "Home health agency care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your$500 deductible applies to out-of-network home health services. This cost sharing is a contractual obligation that had not been met at the time home health care was received on October 25, 2019.Therefore, $350 has been applied to meet your deductible. Since your $500 has been met you have also been asked to pay $151.27. The records show that the provider is out-of-network. 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 cost share for home health care provided from October 25, 2019 through November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).You asked the Plan to pre-approve continued CPAP use. The Plan denied your request. The Plan says that the medical information shows you were not adherent to therapy.The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.We looked at the file and Medicare rules. The compliance report included with the file indicates you did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued CPAP use have not been met.Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on January 14, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.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 the office visit (99213) provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo dental extractions.You asked the Plan to pre-approvethe extractions. The Plan denied your request.The Plan says you have already been approved for two extractions.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 services are subject to a benefit limitation. The plan covers two dental extractions per calendar year. The records show that you were approved for two dental extractions on May 13, 2020. This means that the requested extractions will exceed the benefit limit.Therefore, we decided that the Plan does not have to pre-approvetwo dental extractions.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on February 28, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is covered when the above LCD criteria are met. 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 testing. Our reviewer says that the requested DecisionDx-Melanoma testing was not medically reasonable and necessary. Our physician reviewer found that the documentation does not support that the enrollee is being considered for SLNB to determine eligibility for adjuvant therapy. There was no documented uncertainty regarding the adequacy of microstaging, nor was there documentation of other adverse features. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on February 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDarzalex (J9145).You asked the Plan to pre-approveDarzalex. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Darzalex. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Darzalex is approved by the FDA and supported in the CMS approved compendia in the requested combination if there have been at least two prior therapy regimens. The enrollee has only had one prior regimen. Therefore the documentation does not support that Darzalex is medically reasonable and necessary or safe and effective 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 Darzalex have not been met.Therefore, we decided that the Plan does not have to pre-approveDarzalex (J9145)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided January
8, 2020 to January 15, 2020.
You asked the Plan to pay for the ambulance transportation. You say that the ambulance transportation was
medically necessary. The Plan denied your request. The Plan says ambulance transport to a physician's office is
not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0425, A0428)
provided January 8, 2020 to January 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on March 9, 2020.
You asked the Plan to waive the copayment for the cystoscopy. You say that no one explained to you that there
would be a copayment. You say you thought this would be covered as a preventive service. The Plan denied
your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for an outpatient hospital facility.
You have been asked to pay a $350 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit
category. The medical record shows a history of urethral malignancy which makes the procedure diagnostic in
nature.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the cystoscopy provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertebral axial decompression with a chiropractor.
You asked the Plan to pre-approve the surgery. You say that this is needed to help relieve pain the lower back. The Plan denied your request. The Plan says this is not a covered benefit.
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 pre-approve vertebral axial decompression with a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy.
You asked the Plan to pre-approve percutaneous laminotomy/laminectomy. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 percutaneous
laminotomy/laminectomy. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain
related to spinal stenosis. The percutaneous procedure remains experimental. More research is needed to show
safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of percutaneous laminotomy/laminectomy have not been met. Therefore, we
decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops.You asked the Plan to pre-approve Xiidraeye drops. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.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 Xiidra eye drops.Benefits for Xiidra eye drops may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora sleep study (95811) provided on November 13, 2019.You asked the Plan to waive the coinsurance fora sleep study. You say that if you had known the cost you would not have had this service.The Plan denied your request. The Plan says this processed 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 20% coinsurance for sleep studies. You have been asked to pay a $132.65 coinsurance for a sleep study ($663.24allowed amount x 20% = $132.64). 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 fora sleep study (95811) provided on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on December 11, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly whattests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 drug testing services provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical trays rendered on December 10, 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 A4550 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. The Plan submitted a claim for procedure code A4550. This code has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the surgical trays rendered on December 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAimovig auto-injectors.You asked the Plan to pre-approveself-administered drug. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveAimovig auto-injectors.Benefits for self-administered drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.