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

We decided that the Plan does not have to pay for the physician services provided on December 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 1,
2019 through December 2, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay was medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the record does not show that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two midnights. The enrollee was stable at the time of
admission. The treatment plan included consultation with several specialists regarding plan of care. Although
the enrollee signed out against medical advice, the surgeon stated that she was stable for discharge with further
management in the outpatient setting at that time. Inpatient admission was 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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from December 1, 2019 through
December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre system, continuous glucose monitor.
You asked the Plan to pre-approve the continuous glucose monitor. You say that you are appealing for the prior
authorization for the Freestyle Libre system. The Plan denied your request. The Plan says the enrollee does not
meet the Medicare LCD criteria for the Freestyle Libre.
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 the continuous glucose monitor. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee is noted to have type II diabetes, for which she does not take
insulin. While the enrollee has apparently used a CGM for a while, there is no evidence that the enrollee is
using the results of such monitoring to self-adjust, self-administered insulin, multiple times a day. As such, the
use of a CGM is not shown to be medically necessary or reasonable.
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 continuous glucose monitor have not been met. Therefore, we decided that
the Plan does not have to pre-approve the Freestyle Libre system, continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea cervical collar (L0180).You asked the Plan to pre-approvethe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 orthosis. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is not evidence the L080 brace is reasonable and necessary for the diagnosis or treatment of the patient's chronic neck pain or to improve the functioning of a malformed body member. The documentation does not reveal cervical spine instability, recent surgery or trauma. There is no evidence that the patient requires occipital and mandibular support for her condition or extenuating factors why the patient would require this brace for chronic cervical pain due to spondylosisas this device is not proven to be necessary to improve the function of this patient's condition. 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 orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea cervical collar (L0180).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on October 18, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the claim should be paid. The Plan denied your request. The Plan says the evaluation did not take place at a qualifying originating site.
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 orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve progressive sunglasses from an out-of-network
provider.
You asked the Plan to pre-approve the progressive sunglasses. You say that you need progressive lens in order
to drive. You want to go out of plan because you have tried to get a correct pair of glasses 5 times from the inplan
provider The Plan denied your request. The Plan says enrollee's must receive their vision services from an
in-network provider.
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 on when provided from a plan optical facility..
We looked at the file and the Plan's rules. The plan provides a $40 allowance toward the purchase price of
eyewear from a plan optical facility. Based on this information, we decided that the Plan's rules for coverage of
the progressive sunglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve
progressive sunglasses from an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical techniques requiring use of robotic surgical system coded S2900 provided on January 13, 2020.
You asked the Plan to pay for the surgical techniques requiring use of robotic surgical system. 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 a covered benefit.
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 S2900 is surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure). We find that CPT code S2900 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the surgical techniques requiring use of robotic surgical system have not been met. Therefore, we decided that the Plan does not have to pay for the surgical techniques requiring use of robotic surgical system coded S2900 provided on January 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cyclobenzaprine tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve cyclobenzaprine tablets.
Benefits for self-administered drugs 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: Practitioner Services
Decision: Unfavorable

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

We decided that the Plan does not have to pay for physical therapy services provided on November 4, 2019.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 physical therapy services. 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 for physical therapy services provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.You asked the Plan to pre-approve the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.The Plan denied your request. The Plan says you do not meet the criteria established to receive the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments for 2020.The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit yourhealth or general functioning.In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that yourmedical conditions are not eligible medical conditions under the Plan's debit card allowance benefit. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on December 12, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you should not be responsible for this amount. You say you already paid your copayment. 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 20% for Medicare-covered Part B medications including, but not limited to chemotherapy and drugs used during outpatient diagnostic procedures. You have been asked to pay $61.60 which is 20% of the allowed amount for the Part B injection. The allowed amount is $308. ($308 x 20% = $61.60). The Part B injection falls within the "Medicare Part B prescription drugs (PA)" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B injection provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the surgical services you received on October 14, 2019, and October 15, 2019.
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says your Point-of-Service benefit has a 20% coinsurance.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Point-of-Service coverage. Review of the file shows that you received out-of-network surgical services on October 14, 2019, and October 15, 2019. The services were allowed at $22,216, 29. You have been asked to pay a 20% coinsurance for the services, totaling $4,443.26. The services fall within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the surgical services you received on October 14, 2019, and October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forElectroencephalogram (EEG) extended monitoring (95813) provided August 13, 2019 by Red Rock Neurodiagnostic Services, PLLC.You asked the Plan to pay forthe EEG. You say that the services were billed correctly.The Plan denied your request. The Plan says code 95813 is not supported in the records.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 95813 is Electroencephalogram (EEG) extended monitoring; 61-119 minutes.We find that CPT code 95813 is not supported in the medical record. Specifically, the medical records submitted do not include documentation ofElectroencephalogram (EEG) extended monitoring; 61-119 minutes being performed on August 13, 2019. Based on this information, we decided that Medicare rules for coverage of the EEG have not been met.Therefore, we decided that the Plan does not have to pay forElectroencephalogram (EEG) extended monitoring (95813) provided August 13, 2019 by Red Rock Neurodiagnostic Services, PLLC.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on October 30, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that you cannot afford the copayments due to financial hardship. 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 $30 copayment for each specialist visit for Medicare-covered benefits (including telehealth services). You have been asked to pay a $30 copayment for each of the specialist office visits. The specialist office visits fall 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 copayments for the specialist office visits provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided from October 22, 2019 to October 29, 2019.
You asked the Plan to pay for home infusion services. You say that the Centers for Medicare and Medicaid Services (CMS) website lists this as a valid code. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this procedure code is not valid for Medicare purposes and is not payable.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services provided from October 22, 2019 to October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from September 18, 2018 through December 23, 2019.You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered due to the quality of care received.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the dental services provided from September 18, 2018 through December 23, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove for a pneumatic compression device (E0650).
You asked the Plan to preapprove for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says you do not have a covered indication for coverage of a pneumatic compression device.
The Plan follows Medicare rules. The rules state that a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Since the pneumatic compressor is not medically necessary, your request for the non-segmented appliance/sleeve (E0666) and Segmental gradient pressure pneumatic appliance, half leg (E0673) is also not medically necessary. Therefore, we decided that the Plan does not have to preapprove for a pneumatic compression device (E0650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forin-network benefit coverage for a MyoPro myoelectric orthosis (L8702).You asked the Plan to pay fora MyoPro myoelectric orthosis (L8702). You say that it would seem appropriate to grant the enrollee coverage for the reasonable and necessary brace in question.The Plan denied your request. The Plan says this item is considered experimental and investigational. Medical studies haven't proven that this device is helpful for the treatment of your health problem.The Plan must follow Medicare rules. Medicare rules say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro myoelectricorthosis (L8702) have not been met.Therefore, we decided that the Plan does not have to pay forin-network benefit coverage for a MyoPro myoelectric orthosis (L8702).