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

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on February 4, 2020. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0482 remains not supported. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3)method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the medical records provided do not include documentation from a primary physician validating an evaluation and management visit to establish a relationship between the ordering physician and the enrollee and documenting
exactly which tests were to be performed and the reason for the testing. Because the medical documentation lacks information to validate the patient/physician relationship, this service cannot be verified. 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 pay for drug testing services (HCPCS G0482) provided to the enrollee on February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that your function has decreased since COVID-19 restrictions were put in place.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. You do not require the level of therapies provided in an IRF. You will not be able to make a significant functional recovery within a reasonable and predicted period of time in an IRF. Your rehabilitation needs can be met at a lower intensity setting such as a skilled nursing facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma injections provided from March 11, 2020 to May 11, 2020.
You asked the Plan to pre-approve the services provided. You say that you have tried other modalities to relieve pain, and none of these worked. The Plan denied your request. The Plan says medical necessity for the service has not been established.
The Plan must follow Medicare rules. Medicare rules say that Blood-Derived Products for Chronic Non-Healing Wounds is only covered under certain medical indications. The file shows that platelet-rich plasma injections to the shoulder were provided. We looked at the file and Medicare rules. The information provided does not show that the Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet-rich plasma injections provided from March 11, 2020 to May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical face masks.
You asked the Plan to pre-approve the face masks. You say that you need the face masks to protect against COVID 19. If this is going to be the way of life and for you to be able to do your daily things you need to be protected with masks. The Plan denied your request. The Plan says this item is not covered.
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 the surgical face masks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve a scooter. You say that you need a scooter to go to appointments, family
functions and shopping. The Plan denied your request. The Plan says the record does not show you have
mobility limitations significantly impairing your ability to participate in MRADLs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file shows you do not have a mobility deficit that impairs your participation in MRADLs. The PMD will
be stored outside because of no room in your home. The item at issue in this appeal is being requested for use
outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use
only outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore,
we decided that the Plan does not have to pre-approve a power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) progressive lenses (V2781) and antireflective
coating (V2750) purchased January 27, 2020 from an out-of-network provider.
You asked the Plan to pay for the vision services. You say that you were referred to this provider by an innetwork
provider and you feel that this should be covered. The Plan denied your request. The Plan says vision
services rendered by an out-of-network provider is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when provided by an in-network provider.
We looked at the file and the Plan's rules. Vision services must be provided by an a in-network provider. Based
on this information, we decided that the Plan's rules for coverage of the vision services have not been met.
Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) progressive lenses
(V2781) and anti-reflective coating (V2750) purchased January 27, 2020 from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve second opinion visit. You say that you are requesting a second opinion to assist in determining the best treatment for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can receive a second opinion visit within the Plan 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for endovenous ablation therapy (36478) provided on January 28, 2020 through February 5, 2020.You asked the Plan to pay for the endovenous ablation therapy. You say that you would like reconsideration as this service was billed correctly.The Plan denied your request. The Plan says that diagnosis code is not listed as supporting medical necessity.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 36478 is supported in the record. Specifically, per Medicare's Local Coverage Article: Billing and Coding: Treatment of varicose veins of the lower extremity (A57781), diagnosis code I87.2 supports the medical necessity of CPT code 36478. Based on this information, we decided that Medicare rules for coverage of the endovenous ablation therapy have been met.Therefore, we decided that the Plan has to pay for endovenous ablation therapy (36478) provided on January 28, 2020 through February 5, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required moderate assistance with standing. The enrollee required maximum assistance with transfers and activities of daily living. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive inpatient rehabilitation therapy program. While the enrollee does required physical therapy and occupational therapy services, the enrollee's needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from June 10, 2018 to June 13, 2018.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with how the claims were separated.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $450 copayment each day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from June 10, 2018 to June 13, 2018. Therefore, you are responsible to paya $450 copayment for days 1-3 (June 10, 2018 to June 12, 2018). $450 (copayment) x 3 (inpatient days) = $1,350.You have been asked to pay the total copayment amount of $1,350 for an inpatient hospital stay. An 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 foran inpatient hospital stay provided from June 10, 2018 to June 13, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 20, 2020.
You asked the Plan to pay for the 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 the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine Pamoate.
You asked the Plan to pre-approve Hydroxyzine Pamoate. You say that the enrollee has tried different medications that made her nauseous and vomit. The Plan denied your request. The Plan says the drug is not covered for the enrollee's condition by the Part B plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroxyzine Pamoate.
Benefits for Hydroxyzine Pamoate 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe psychotherapy services (90832). You say that you would like reconsideration because these services were medically necessary and requested by the nursing home.The Plan denied your request. The Plan says there was no approved prior authorization on file to cover the 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 forthe medical services provided on October 1, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on January 7, 2020.You asked the Plan to pay forthe lab services. The Plan deniedyour request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided on January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androgel.
You asked the Plan to pre-approve Androgel. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Androgel is not covered under your Medicare Part B 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-approve Androgel.
Benefits for Androgel 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration (D9610), surgical placement of implant body: endosteal implant (D6010), prefabricated abutment - includes modification and placement (D6056), sinus augmentation via a vertical approach (D7952), sinus augmentation with bone or bone substitutes via a lateral open approach (D7951) and removal of impacted tooth - completely bony (D7240). You asked the Plan to pre-approve these services. You say that your gums and bone are deteriorating. The Plan denied your request. The Plan says that these services are not covered by 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 pre-approve therapeutic parenteral drug, single administration (D9610), surgical placement of implant body: endosteal implant (D6010), prefabricated abutment - includes modification and placement (D6056), sinus augmentation via a vertical approach (D7952), sinus augmentation with bone or bone substitutes via a lateral open approach (D7951) and removal of impacted tooth - completely bony (D7240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an orthopedic office visit provided on January 24, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that based on your benefits there should only be a $15 copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $25 copayment for out-of-network specialist visit. You have been asked to pay $25 copayment for out-of-network specialist visit. Specialist 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 for an orthopedic office visit provided on January 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for an MRI with an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be provided in 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 Plandoes not haveto pre-approvea referral for an MRI with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topreapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).