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

We decided that the Plan does not have to pre-approve moderate sedation (99152).You asked the Plan to pre-approve the moderate sedation. You say that the member has a phobia of needles so the moderate sedation is medically necessary. The Plan denied your request. The Plan says moderate sedation is 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 the moderate sedation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found epidural steroid injections are typically performed in an ambulatory setting without sedation and without monitored anesthesia care. The provided records do not clearly demonstrate the need for moderate sedation as opposed to local anesthesia or minimal sedation. 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 moderate sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve moderate sedation (99152).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - three surfaces provided on April 30, 2019.
You asked the Plan to pay for the resin-based composite - three surfaces. You say that you could not eat due to the condition of your molars and the subsequent pain. You also say that you saw this provider on an emergency basis. The Plan denied your request. The Plan says this service is not covered under the plan.
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 the resin-based composite - three surfaces provided on April 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an office visit. You say that you have an in-grown toenail you need taken out. You possibly need orthopedic shoes as you are a diabetic. In addition, you feel comfortable staying with the physician since you have been there before.The Plan denied your request. The Plan says the physician is a non-contracted provider with the Plan. The Plan has in-network podiatrists for the needed services. Your primary care physician may refer you to an out-of-network provider when your medical needs cannot be met through the Plan's network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection (73140, G0463, J0702, 20550) provided September 13, 2019
You asked the Plan to waive the copayment for the injection. You say that the services were provided in the doctor's office and you were not an outpatient. The Plan denied your request. The Plan says the provider bills all surgical procedures through the hospital. Injections are considered an outpatient surgical procedure.
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 Outpatient Surgery. You have been asked to pay a $250 copayment for the injection. The injection falls within the Outpatient Surgery 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 an injection (73140, G0463, J0702, 20550) provided September 13, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacupuncture.You asked the Plan to pre-approveacupuncture. You say that this is medically necessary for the enrollee's mental health.The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture has been requested to treat depression and other mental health issues rather than chronic low back pain.Therefore, we decided that the Plan does not have to pre-approveacupuncture.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiogram with doppler complete for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this request does not meet medical necessity criteria.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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the record, the enrollee had transient atrial fibrillation associated with transient left ventricular dysfunction and mitral regurgitation. The most recent echo only 4 month ago showed return to normal ventricular function with only mild mitral regurgitation and the patient remains clinically stable. At this time the documentation does not support the medical necessity for a repeat echocardiogram in a clinically stable patient, 4 months after the prior exam. Current guidelines also do not consider a repeat echocadiogram appropriate in this setting.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 pre-approve transthoracic echocardiogram with doppler complete for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the cervical spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says the guidelines say that there must be doctor's notes that show neck stretches (physical
therapy, chiropractic treatments, or medically directed home exercise program) for six weeks in the last six
months.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no red flags
reported in the records. In particular the physical exam on 12/5/19 describes 8/10 pain exacerbated with
movement but no neurological deficit. The records show no attempt at conservative therapy within the last 6
months.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI of the cervical spine for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) for the
enrollee.
You asked the Plan to pre-approve the MRS. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that Medicare considers MRS to be experimental and
investigational.
This type of imaging is statutorily not covered. Based on this information, we decided that Medicare rules for
coverage of the MRS have not been met. Therefore, we decided that the Plan does not have to pre-approve
magnetic resonance spectroscopy (MRS) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (0042T) provided to the enrollee on October 13, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that LCA A57743 provides a list of non-covered services. We looked at the file and Medicare rules.Per A57743, code 0042T is non-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 forthe services (0042T) provided to the enrolleeon October 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on May 7, 2019 through July 3, 2019.
You asked the Plan to pay for the home health services. You say that you privately paid an out-of-network wound care specialist because you needed someone to properly treat the wound in order to avoid further complications. The Plan denied your request. The Plan says you have not submitted any proof of payment for the outside services nor any records to confirm the level or type of care you privately paid for.
The Plan must follow Medicare rules. The rules say that that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services.
We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, prior authorization was not obtained to receive outside care services. Additionally, the record does not include provider information, invoices or proof of payment. Therefore, we decided that the Plan does not have to pay for home health services provided on May 7, 2019 through July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet injections.You asked the Plan to pre-approvethe requested service. The Plan denied your request. The Plan says you have not tried physical therapy.The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered under certain medical indications. 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 requested service. Our physician reviewer found that you have low back pain following a motor vehicle accident. The magnetic resonance imaging (MRI) shows chronic degenerative changes including facet joint disease. You are currently taking Belbucca, Percocet and Tizanidine for pain. There is no documentation of physical therapy, a home exercise program, or of an NSAID trial. You have not had an adequate trial of conservative therapy. Therefore, the request, at this point, is not medically reasonable or 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 the requested service have not been met. Therefore, we decided that the Plan does not have to pre-approvelumbar facet injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliances provided by Trimed Services on August 12, 2019.
You asked the Plan to pay for the pneumatic device (E0673) and appliances (E0655).. You say that the proof of delivery is valid. The Plan denied your request. The Plan says the documentation submitted is for a different date than the billed date of service.
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 and proof of delivery for the supplies provided in this case. The claim has an incorrect date of service. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliances provided by Trimed Services on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood pressure monitoring provided on September 24, 2019.
You asked the Plan to pay for the blood pressure monitoring. You say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulatory blood pressure monitoring must be performed for at least 24 hours and services provided during transport are not paid separately.
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 A4670 is Automatic blood pressure monitor.
Blood pressure monitoring is included in the Medicare fee schedule for ambulance services. Based on this information, we decided that Medicare rules for coverage of the blood pressure monitoring have not been met. Therefore, we decided that the Plan does not have to pay for the blood pressure monitoring provided on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.
You asked the Plan to pre-approve these services. You say that you have a family history of cancer. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that BRCA testing is covered for beneficiaries with a personal history of breast, ovarian, pancreatic, or prostate cancer. We looked at the file and Medicare rules. The file shows that you do not have a personal history of cancer for which BRCA testing is covered. 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 BRCA genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 16, 2019.You asked the Plan to pay forthe orthoses. You say that that the orthoses shipped should be covered by the plan.The Plan denied your request. The Plan says the records provided do not support the service billed.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 delivery ticket submitted did not include the carrier's tracking number, the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted and is not itemized to indicate specific supplies.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoffice visits (999215, 99205) to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoffice visits. The record shows that you did not provide any arguments in favor of coverage.The Plandenied your request. The Plan says that youarerequiredto receive care from providers who are part of your primary care physician's (PCP) specialty network. Your medical group has several providers in the specialty who can evaluate you and treat you foryour medical condition. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.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 careand care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exceptionthat would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approveoffice visits (999215, 99205) to be provided by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Humira Pen.
You asked the Plan to pre-approve a Humira Pen. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the Humira Pen is intended for patient self-administration and is not covered under 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 a Humira Pen.
Benefits for a Humira Pen 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a collagenase clostridium injection (J0775) provided May 23, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 Part B Drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Part B 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 a collagenase clostridium injection (J0775) provided May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network retina specialist.You asked the Plan to pre-approve these services. You say that there are no in-network retina specialists.The Plan denied your request. The Plan says the services are available from network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan confirmed that there is a retina specialist available in-network. 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 a referral to an out-of-network retina specialist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on November 20, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be responsible for the copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan mustdisclose 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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls 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 copayment forthe specialist office visit provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on August 28, 2019.You asked the Plan to pay forthe 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. Medicarerules 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 decidedthat the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on August 28, 2019.