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

We decided that the Plan does not have to pre-approve Prothrombin coagulation factor II, factor V and JAK2 gene analysis identified with codes 81241, 81240, and 81270.You asked the Plan to pre-approve Prothrombin coagulation factor II, factor V and JAK2 gene analysis services. 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 follows Medicare rules. Medicare rules say that factor V is non-covered. Medicare rules also say that Prothrombin coagulation factor II and JAK2 gene analysis services are only covered for certain 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 Prothrombin coagulation factor II, factor V and JAK2 gene analysis services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a DVT of the right femoral vein after a long car ride. The family history is notable for a heart attack in the father, and a post-operative pulmonary embolism in the mother. The documentation does not support that the enrollee has a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of Prothrombin coagulation factor II, and JAK2 gene analysis. Factor V is non-covered. 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 Prothrombin coagulationfactor II, factor V and JAK2 gene analysis services have not been met.Therefore, we decided that the Plan does not have to pre-approveProthrombin coagulation factor II, factor V and JAK2 gene analysis identified with codes 81241, 81240, and 81270.
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 you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered.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 thisappeal. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 19, 2020.
You asked the Plan to pay for the assembly and operation of a pump. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the length of the procedure. The Plan denied your request. The Plan says payment for this service is included in the DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hydrocele repair provided on February 26, 2020.
You asked the Plan to waive the copayment for the hydrocele repair. You say that the explanation of benefits doesn't reflect the amount you paid. You say that you are requesting a refund if warranted. The Plan denied your request. The Plan says the copayment 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 $325 copayment for outpatient surgery.
You have been asked to pay a $325 copayment for the hydrocele repair. The hydrocele repair falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The hydrocele repair is considered a surgical procedure. 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 hydrocele repair provided on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3 (J7328). You say that you want the enrollee to be treated with
Gelsyn-3 (J7328) for quality of life. The Plan denied your request. The Plan says the enrollee has not first tried
and had a contraindication or intolerance to Orthovisc and Monovisc.
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 Gelsyn-3 (J7328). Our reviewer says
that the drug is not medically necessary. Our physician reviewer found the case file does not contain
documentation of trial and failure of Orthovisc and Monovisc. The documentation does not support that
Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the
enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gelsyn-3 (J7328) have not been met. Therefore, we decided that the Plan does
not have to pre-approve Gelsyn-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you are shaking and having trouble checking your blood sugar. The Plan denied your request. The Plan says there is no documentation that you are testing four or more times a day.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no glucose logs in the file documenting testing. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are now mostly contact guard assist (CGA)-to-supervised for all care. You have no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care (including home health care services or custodial center placement). SNF care is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 27, 2020.
You asked the Plan to pay for assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that the enrollee needs a Group 3 power wheelchair, accessories, and power seat elevation feature. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingevectomy/gingivoplasty to allow access for restorative procedure, tooth 25 (D4212).
You asked the Plan to pre-approve the dental service. You say that the records provided should support the necessity of the service. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 pre-approve gingevectomy/gingivoplasty to allow access for restorative procedure, tooth 25 (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the progressive lenses (V2781).
You asked the Plan to pre-approve the lenses. You say that you feel that this should be approved because for
over 22 years you've only had progressive lenses and the Plan had paid for it the last time which was about 2
years ago. The Plan denied your request. The Plan says this is not covered under the plan benefits.
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 does not cover progressive lenses.
We looked at the file and the Plan's rules. Progressive lenses is not covered under the plan benefits. Based on
this information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we
decided that the Plan does not have to pre-approve the progressive lenses (V2781).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic mammogram and the
tomosynthesis provided on February 4, 2020.
You asked the Plan to waive the copayments for the diagnostic mammogram and the tomosynthesis. You say
that you should not be responsible for the copayment for the second mammogram because it is not your fault a
clear picture was not taken the first time. 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 $90
copayment for each covered x-ray in the outpatient department of a network hospital or facility and a $300
copayment covered diagnostic radiology services in the outpatient department of a network hospital or facility.
You have been asked to pay a $90 copayment for the diagnostic mammogram and $30.67, which is less than
the standard copayment amount, for the tomosynthesis. The diagnostic mammogram and the tomosynthesis fall
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record
shows you had already received a screening mammogram in 2020.
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 diagnostic mammogram and the tomosynthesis
provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory infectious agent detection coded 87633 provided on Jauary 15, 2020.
You asked the Plan to pay for the respiratory infectious agent detection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the respiratory infectious agent detection services coded 87633 is non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the respiratory infectious agent detection have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory infectious agent detection coded 87633 provided on Jauary 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic visit provided on November 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient clinic visit. You say that these services are provided in good faith. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 outpatient clinic visit provided on November 13, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 21, 2018 to November 22, 2018.
You asked the Plan to waive the copayment for the inpatient hospital stay. You submitted your bill for review. You say you would like to know if you have to pay for this 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 $325 copayment for each day from days 1 through 5, per benefit period, for Medicare-covered inpatient hospital care. You have been asked to pay a $325 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" 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 the inpatient hospital stay provided from November 21, 2018 to November 22, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your current orthotics are worn and no longer provide relief. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on November 12, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says all non-emergent services received with a non-Plan provider require approval by the Plan prior to the services being rendered.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the psychotherapy services providedon November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea powered upper extremity range of motion assist device.You asked the Plan to pre-approvea powered upper extremity range of motion assist device (L8702). You say that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living.The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational, are not covered.  We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. The requested limb orthosis continues to be denied because of insufficient evidence of its effectiveness. Based on this information, we decided that Medicare rules for coverage of a powered upper extremity range of motion assist device (L8702) have not been met.Therefore, we decided that the Plan does not have to pre-approvea powered upper extremity range of motion assist device.
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on September 18, 2019.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring System.You asked the Plan to pre-approvea continuous glucose monitor. You say that a CGM would save you from multiple sticks daily.The Plan denied your request. The Plan says you do not meet criteria for a CGM. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record does not show you require frequent insulin adjustments based on testing. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose MonitoringSystem