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

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 19, 2019 to November 7, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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 proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description ofthe items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 19, 2019 to November 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pay for more than 30 minutes of hospital discharge day management services (99239) provided on May 12, 2019.You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the recordssubmitted. The Plan denied your request. The Plan says the documentation submitted does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more for the billed date of service of 05/12/2019.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 99239 is hospital discharge day management; more than 30 minutes. 
We find that CPT code 99239 is not supported in the record. Specifically, the record does not indicate that more than 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on May 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard testing.You asked the Plan to pre-approveCologuard testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requested testing.The Plan must follow Medicare rules. Medicare rules say that Cologuardtesting is only covered for certain indications.Review of the file shows that the documentation supports that you had a positive fecal immunochemical test screening test done in August 2019. The documentation also supports that you have a history of adenomatous polyps removed during your last colonoscopy in 2013. This means that you do not meet the asymptomatic and at average risk of developing colorectal cancer criteria for the requested services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cologuard testing have not been met.Therefore, we decided that the Plan does not have to pre-approveCologuard testing
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) provided on October 2, 2019.You asked the Plan to pay forthe dental service. You say that you were advised by a Plan representative before your appointment that you had not used any of your dental benefits for the year.The Plan denied your request. The Plan says the frequency limit has been exceeded.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.Thoughthe Plan offers a dental benefit in excess of Medicare coverage and period oral evaluations are a covered service, the frequency limit of once per calendar year has been exceeded. The record shows that you last received this service on July 11, 2019.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) provided on October 2, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvescaling in presence of generalized moderate or severe gingival inflammation and gingival irrigation.You asked the Plan to pre-approvethe scaling and gingival irrigation. You say that your gums are in bad shape.The Plan denied your request. The Plan says these services are not covered under your benefit package.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-approvescaling in presence of generalized moderate or severe gingival inflammation and gingival irrigation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical alert device.You asked the Plan to pre-approvemedical alert device. You say that it is your opinion that the enrollee would benefit from a medical alert device and recommend insurance cover this service.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that medical alert devices are not covered because they are not primarily medical in nature. While a medical alert device may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvethe medical alert device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a monitoring feature (A9279) provided on May 6, 2019.You asked the Plan to pay for the monitoring feature. You saythat you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code A9279 has a status code of I.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 A9279 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, A9279 has a status code of I. This means that A9279 is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the monitoring feature have not been met. Therefore, we decided that the Plan does not have to pay for a monitoring feature (A9279) provided on May 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99152) provided on July 9, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older".We asked our coding 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 use of CPT 99152 is not supported by the records provided. Our coding reviewer found that the record does not contain evidence that moderate sedation was performed with the presence of a trained, independent observer.We looked at this coder'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 forthe services (CPT 99152) provided on July 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora pre-operative electrocardiogram (93010) provided on July 15, 2019.You asked the Plan to pay fora pre-operative electrocardiogram. You say that this was denied in error.The Plan denied your request. The Plan says diagnostic testing as part of a pre-operative examination is not covered under the Medicare.The Plan must follow Medicare rules. Medicare rules say that claims submitted for tests such as electrocardiograms performed solely as part of a preoperative examination, without additional diagnoses indicating medical necessity, will be denied as not reasonable and necessary.We looked at the file and Medicare rules. The record shows this electrocardiogram was performed as part of a preoperative examination and billed only with diagnosis code Z01.810: encounter for preprocedural cardiovascular examination. Based on this information, we decided that Medicare rules for coverage of a pre-operative electrocardiogram have not been met.Therefore, we decided that the Plan does not have to pay fora pre-operative electrocardiogram (93010) provided on July 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. Yousay that the enrollee has been found by physical therapy to be a high fall risk and unsafe to return home without more rehab.The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy at this time.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 todetermine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 1/9/2020 with chest pain,shortness of breath and dizziness. Initially, the enrollee had syncope on 12/30/19, warranting admission. The enrollee's history is notable for a stable cerebellopontine mass, likely a Schwannoma. She is now afebrile and able to make needs known. The enrollee now mostly requires contact guard assist to supervision for all care. She has no complex wound care needs and no IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level ofcareWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 5, 2019 through August 12, 2019.You asked the Plan to pay for the home infusion therapy. You say that S9328 is a valid code per CMS. The Plan denied your request. The Plan says procedure code S9328 has a status code of I which is not valid for Medicare purposes.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 S9328 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status code of I. This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 5, 2019 through August 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2 additional extractions (D7210), and 2 implants (D6010) provided on February 7, 2019.You asked the Plan to pay for2 additional extractions, and the implants. The Plan denied your request. The Plan says the frequency limit for extractions has been exceeded. The Plan says that 2 extractions are covered per calendar year. The Plan also says that implants are not listed as a covered service.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 and extractions are listed as a covered service, the frequency limit of 2 extractions per calendar year has been exceeded. The record shows that the Plan previously paid for two of the extractions received on February 7, 2019. Additionally, implants are not listed as a covered service.Therefore, we decided that the Plan does not have to pay forthe 2 additional extractions (D7210), and 2 implants (D6010) provided on February 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider,"the doctor". You asked the Plan to pre-approve the office visits and testing. You say that the nearest network provider is 50 miles away. The Plan denied your request. The Plan says you do not have any out-of-network benefits except in specific cases which are outlined in the EOC.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 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. 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 the medical services to be provided by out of network provider, "the doctor".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXifaxan.You asked the Plan to pre-approveXifaxan. You say that you would like the planto reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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-approveXifaxan. Benefits for Xifaxanmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee is ready for transfer to an LTACH.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The plan says that the services needed can be provided in another setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having initially been admitted for scheduled repair of an umbilical hernia. The enrollee was found to have a colonic mass resulting in a colectomy. This was complicated by an anastomotic leak and abscess formation. The enrollee is receiving wound care, antibiotics and supplemental nutrition. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAmbien 10mg tablet (J8499).You asked the Plan to pre-approveAmbien 10mg tablet. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveAmbien 10mg tablet (J8499).Benefits for Ambien 10mg tabletmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction by neurolyticagent services coded 64636 provided on March 12, 2019.You asked the Plan to pay forthe destruction by neurolytic agent services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manualdefinition of code 64636 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure).We findthat CPT code 64636 is not supported in the medical record. Specifically, the documentation submitted do not indicate that destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint was performed; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the destruction by neurolytic agent services have not been met.Therefore, we decided that the Plan does not have to pay forthe destruction by neurolytic agent services coded 64636 provided on March 12, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder orthosis (L3660) provided on July 19, 2019.You asked the Plan to pay forthe orthosis. You say that that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says the billed services are not supported.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 physician order for the items at issue in this appeal. The record does not contain a valid physician order to indicated the specific supplies for the billed  date of service for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay forthe shoulder orthosis (L3660) provided on July 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on August 1, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were not informed of anything being removed or biopsied. You say that you shouldn't be responsible for that.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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that three polyps were removed, which makes this 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 forthe colonoscopy provided on August 1, 2019.