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

We decided that the Plan does not have to pay for breast tomosynthesis (77062) provided on September 11, 2019.You asked the Plan to pay for the breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code 77062 has 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 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77062 has a status codeof I. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for breast tomosynthesis (77062) provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration as these services were medically necessary. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services (G0299, G0156, and G0151) provided on May 3, 2019 to July 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forhome health services. You say that an in-network provider was not available.The Plan denied your request. The Plan says these services were not authorized and in-network providers are able to provide the services at issue.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 thePlan does not have to pay forhome health services (G0299, G0156, and G0151) provided on May 3, 2019 to July 20, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa injections for the enrollee.You asked the Plan to pre-approveEuflexxa. You say that this is being used to treat the member's knee pain.The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee. The enrollee is noted to have osteoarthritis. The health plan requires that Monovisc and Orthovisc be used first. There is no evidence that the enrollee is allergic to or intolerant of Monovisc or Orthovisc. There is no evidence that the enrollee has tried and not responded to Monovisc or Orthovisc. There is no documentation as to why Monovisc and Orthovisc would not be expected to be safe and effective for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa injections for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 17, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab tests billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat lift chair (E1399).
You asked the Plan to pre-approve the power seat lift chair. You say that the recliner seat is too deep. The Plan denied your request. The Plan says your medical needs can be met with your current chair.
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 seat lift chair. Our reviewer says that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage of the power seat lift chair. Our physician reviewer found you received a new power seat lift chair recliner in August 2019. The physical therapist noted that you have one inch between your buttocks and the back of the seat while seated in the chair. The documentation does not support that your medical needs cannot be met with your current chair.
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 power seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat lift chair (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that the item 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. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.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 Freestyle Libre 14 day sensor. Our reviewer says that the item is not medically necessary. Our physician reviewer found you are not on insulin. You do not meet the Plan's coverage criteria for use of the Continuous Glucose Monitoring. It is not medically reasonable and 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 a Freestyle Libre 14 day sensor have not been met.Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient psych admission provided from September 9, 2019 to September 17, 2019.You asked the Plan to pay for the inpatient psych admission. You say that treatment at a lower level of care was not appropriate because the enrollee presented with psychosis and suicidal ideation. The Plan denied your request. The Plan saysthe inpatient psych admissiondoes not meet medical necessity criteria.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psych admission. Our reviewer says thatacute inpatient mental health treatment is note medically necessary and reasonable. Our physician reviewer found that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, he did not have delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others and no delusions. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. The file does not contain an individualized treatment plan. Based upon review the records provided, the admission of this enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others but was without agitationor aggression without delusional thinking.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 inpatient psych admission have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient psych admission provided from September 9, 2019 to September 17, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on June 19, 2019 to August 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for home health services. You say that this is the only company in the area that can provide these services. The Plan denied your request. The Plan says no prior authorization was obtained for 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 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 home health services provided on June 19, 2019 to August 16, 2019 by an out of network (OON) provider
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ED visit provided on October 10, 2019 and laboratory services provided on October 15, 2019 and October 24, 2019.You asked the Planto waive the copayment forthe ED visit and laboratory services. You say that this was a direct result of your previous hospital stay. You say that you shouldn't have to pay these bills.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90 for each Medicare-covered emergency room visit and$20 for Medicare-covered laboratory tests. You have been asked to pay a total of $127.97 for the ED visit and laboratory services. Date of ServiceServiceAllowed AmountStandard CopaymentMember LiabilityOctober 10,2019ED Visit$2,894.47$90$90October 15, 2019Laboratory Tests$17.97$20$17.97October 24, 2019Laboratory Tests$22.34$20$20TOTAL:$127.9 The ED visit falls within the "Emergency care" benefit category. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 topay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ED visit provided on October 10, 2019 and laboratory services provided on October 15, 2019 and October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam, ophthalmic imaging and visual field exam provided on September 12, 2019.
You asked the Plan to waive the copayment for the eye exam, ophthalmic imaging and visual field exam. You say that you were not informed the office visit copayment would not cover the additional services. You say that the additional copayment should be covered. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Medicare-covered vision services and a $75 copayment for Medicare-covered non-radiologic diagnostic procedures and tests. You have been asked to pay a $50 copayment for the eye exam and a $75 copayment for the ophthalmic imaging and visual field exam. The total amount you owe is $125 ($50 + $75 = $125). The eye exam falls within the "Vision care" benefit category. The ophthalmic imaging and visual field exam fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 eye exam, ophthalmic imaging and visual field exam provided on September 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral Orthovisc knee injections with ultrasound.
You asked the Plan to pre-approve the bilateral Orthovisc knee injections with ultrasound. You say that the enrollee makes an excellent candidate for Orthovisc injections. You say that the enrollee is not a candidate for total knee arthroplasty. You say that the records provided support the requested injection services. The Plan denied your request. The Plan says recent medical studies show that the use of the requested medication is not helpful in treating knee pain.
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 the bilateral Orthovisc knee injections with ultrasound. Our reviewer says that the requested Orthovisc knee injections are not medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of bilateral primary osteoarthritis of the knee. The most recent submitted office note dated January 16, 2020 states that the enrollee is "comfortable with her left knee." The records provided do not support the medical necessity of the services in dispute. 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 bilateral Orthovisc knee injections with ultrasound have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral Orthovisc knee injections with ultrasound.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing frame/table system and foot support system
You asked the Plan to pre-approve Standing frame/table system (E0638) and foot support system (E1399). You say that the enrollee needs a standing frame to help with rehabilitation from an injury. The Plan denied your request. The Plan says a standing frame 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 item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a standing frame/table system and foot support system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).You asked the Plan to pre-approve the CGM. You say that you believe that you meet the criteria for the CGM.The Plan denied your request. The Plan says you do not use insulin which is a requirement for coverage of the CGM.The Plan must follow Medicare rules. Medicare rules say that CGMs may be covered for enrollees who perform glucose tests four or more times per day and require three or more daily insulin injections. In this case, the record shows you test once per day and do not use insulin. As such, the Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from February 28, 2019 to May 28, 2019.
You asked the Plan to pay for home infusion therapy. You say that this was medically necessary. The Plan denied your request. The Plan says the billed CPT code 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 medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from February 28, 2019 to May 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services.
You asked the Plan to pre-approve continued services. You say that you are not ready to be sent home to take care of yourself. The Plan denied your request. The Plan says there are no skilled nursing or therapy services.
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. Continued SNF services were requested beyond March 9, 2020. 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 continued services. Our physician reviewer found that from a nursing perspective, you had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you were independent with bed mobility, and at contact guard assist with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on May 29, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the records do not indicate a clear provider intent to order the lab.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 documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 11, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 services at issue in this appeal. The Plan did not pre-approve the services at 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 forthe medical services provided to the enrollee by an out-of-network provider on November 11, 2019.