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

We decided that the Plan does not have to pre-approve Cyclobenzapr Tab.You asked the Plan to pre-approve Cyclobenzapr Tab. You say that the enrollee has been on this medication and finds it helps.The Plan denied your request. The Plan says this medication does not fall under Part B benefits.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 Cyclobenzapr Tab.Benefits for Cyclobenzapr Tab 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 20, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen concentrator to be provided by an out of network (OON) provider at the in network rate.You asked the Plan to pre-approve an oxygen concentrator and portable oxygen concentrator provided at the in network rate. The Plan denied your request. The Plan says that there is a participating in network provider available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if you use an out-of-network provider, your share of the costs for your covered services may be higher..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 at the in network rate.Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen concentrator to be provided by an out of network (OON) provider at the in network rate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toilet rail. You asked the Plan to pre-approve the toilet rail. You say that the enrollee is prone to falling and needs assistance using the bathroom. You say that a delay in the procurement of this device may result in the enrollee falling and injuring herself. You say that the rail will prevent minor to serious injuries. The Plan denied your request. The Plan says the item being requested is not covered by Medicare or by the Plan. The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a toilet rail 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-approve a toilet rail.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound and injection services rendered on May 21, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 76882 and J2001. 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 76882 is ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation. The definition of code J2001 is injection, lidocaine hcl for intravenous infusion, 10 mg. We find that CPT codes 76882 and J2001 are not supported in the medical record. Specifically, there is no documentation of a limited ultrasound of a joint or other nonvascular extremity structure to support code 76882 or that an injection of lidocaine HCl for intravenous infusion was performed to support code J2001. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound and injection services rendered on May 21, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided November 15, 2019 to November 30, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary.The Plan denied your request. The Plan says that services could have been provided at a lower level of care.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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed thatat the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.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 been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided November 15, 2019 to November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95908) and needle electromyography (95886) provided on September 27, 2019.
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that these services were medically necessary. The Plan denied your request. The Plan says the technical report did not include documentation of nerve conduction studies or complete needle electromyography.
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 95908 is nerve conduction studies; 3-4 studies and 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 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 nerve conduction studies and needle electromyography. Our reviewer says that CPTs 95908 and 95886 are not supported in the records. Our physician reviewer found the technical report in the medical records provided does not include documentation on a nerve conduction studies; for 3-4studies, therefore this service cannot be validated as being performed on September 27, 2019. The use of pedical screws, as noted in the medical record, does not meet definition criteria for CPT code 95908. CPT code 95886 is an add-on code. An add-on code is a HCPCS/CPT code that describes a service that is always performed in conjunction with another primary service. An add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on code is never eligible for payment if it is the only procedure reported by a practitioner." In this case, CPT code 95908, the primary service code was denied by the health plan therefore, CPT 95886 is not eligible for separate reimbursement.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95908) and needle electromyography (95886) provided on September 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for physical therapy with an out-of-network provider.You asked the Plan to pre-approve the referral. You say that you feel that the services are medically necessary.The Plan denied your request. The Plan says there are doctors in the plan who can provide this service.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 for physical therapy with an out-of-network provider
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 the clinical information provided supports the need for IRF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of IRF care.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea functional electrical stimulator.You asked the Planto pre-approvethe stimulator. You say that this is medically necessary.The Plandenied your request. The Plansaysthe BIONESS L300 GO plus system is not covered by Medicare as you do not meet the indications.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denyingthe request to pre-approve the stimulator. Our reviewer says that the requested stimulator not considered medically reasonable and necessary in this case. Our physician reviewer found the requested technology is only covered for use in patients with a history of a spinal cord injury who have met additional requirements for coverage. There is no notation of a spinal cord injury. There is no history of surgery.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the stimulator have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea functional electrical stimulator
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 before the enrollee's stroke she was working part time, driving, and was independent. You say that the only therapy the enrollee receives is at her bedside and is very limited. The appellant says that the enrollee's doctor feels she needs a chance to rehabilitation in an IRF before going back home with her spouse.The Plan denied your request. The Plan says the enrollee has no skilled nursing needs or skilled therapy needs. The Plan says that a less intensive level of care is more suited for the enrollee's limited function. The Plan says that the criteria for coverage have not been met.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 requestto 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services. The enrollee's care 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enteral formula, Ensure (B4150).You asked the Plan to pre-approvethe Ensure. You say that you have a bad tooth and cannot eat and due to the Covid 19 crisis you are unable to go to the dentist.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicarerules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approveEnteral formula, Ensure (B4150).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on December 27, 2019.You asked the Plan to pay for the 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.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation services coded 85060 provided on December 18, 2019.
You asked the Plan to pay for the blood smear interpretation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 85060 is blood smear, peripheral, interpretation by physician with written report. We find that CPT code 85060 is not supported in the medical record. Specifically, code 85060 has a physician fee schedule PCTC indicator of 8. The place of service on the claim is 22, outpatient services. The professional interpretation was furnished in a different payment locality from where the TC was furnished. Based on this information, we decided that Medicare rules for coverage of the blood smear interpretation services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation services coded 85060 provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6535.You asked the Plan to pre-approve the compression stockings. You say that the items are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6535 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6535.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided on February 18, 2020, February 19, 2020 and February 20, 2020.
You asked the Plan to waive the copayment for the office visits. You say that the doctors did not resolve the issue. You say that the copayments should be removed. 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 $35 copayment for each specialist visit. You have been asked to pay a total of $95.83 for the office visits.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
February 18, 2020
Office Visit
$78.91
$35
$35
February 19, 2020
Office Visit
$51.30
$35
$35
February 20, 2020
Office Visit
$25.82
$35
$25.82
TOTAL:
$95.83
The 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 copayment for the office visits provided on February 18, 2020, February 19, 2020 and February 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from December 19, 2019 to December 26, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from December 19, 2019 to December 26, 2019.
Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Gralise tablets.
You asked the Plan to pre-approve the Gralise tablets. You say that the Gralise samples have helped the enrollee. You also say that Gralise helps the enrollee maintain her level of activity and functioning, and improves her quality of life. The Plan denied your request. The Plan says the prior authorization request indicates that this medication is to be self-administered by the enrollee. The Plan also says that this medication does not fall under 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 the Gralise tablets.
Benefits for the Gralise tablets 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 pay for the medical services provided on December 19, 2019 by a non-network provider. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 December 19, 2019 by a non-network provider.