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

We decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve provided on December 11, 2019.You asked the Plan to pay forthe knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses are medically necessary.The Plan denied your request. The Plansays the orthoses are not medically 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 pay for the knee orthosis (L1851) and suspension sleeve (L2397). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the enrollee's chief complaint was chronic pain located in knee left. 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 knee orthosis (L1851) and suspension sleeve (L2397) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve provided on December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PILD services.
You asked the Plan to pre-approve the requested services. You say that the service would provide significant clinical and quality of life benefits. The Plan denied your request. The Plan says the requested service is not covered if you are not part of a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that PILD services will be covered for beneficiaries who are enrolled in an approved clinical study. We looked at the file and Medicare rules. The documentation provided does not show the enrollee is part of a Medicare-approved clinical trial. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous image-Guided lumbar decompression (PILD) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the dental services provided on December 6, 2019.
You asked the Plan to provide additional payment for the dental services. You say that these services are fully covered under your preventative service. The Plan denied your request. The Plan says that you may pay more when you receive services out-of-network.
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. The Plan says that you can get care from an out-of-network dental provider but you may pay more. We looked at the file and Medicare rules. The file indicates you went to an out-of-network dentist and the plan paid up to the maximum benefit amount. You are responsible for any charges over that amount. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to provide additional payment for the dental services provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Panoramic X-rays (D0330) provided February 11, 2020.You asked the Plan to pay for the x-rays. You say that the service should be covered.The Plan denied your request. The Plan says the benefit for panoramic X-rays has already been used for this benefit period.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. The Plan covers the x-rays once every 36 months.We looked at the plan contract, the file, and Medicare rules. The record shows the enrollee already had a set of Panoramic X-rays within the past 36 months. Based on this information, we decided that the Plan's rules for coverage of the x-rays have not been met.Therefore, we decided that the Plan does not have to pay for Panoramic X-rays (D0330) provided February 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from November 6, 2019 to November 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 the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment.We looked at the file and Medicare rules. The file shows that the claims were not billed with the correct TOB code. 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 home health services rendered from November 6, 2019 to November 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 33361 provided on October 15, 2019.
You asked the Plan to pay for CPT code 33361. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says Plans shall pay TAVR claim lines billed with CPT code 33361 in a clinical trial only when billed with an 8-digit national clinical trial number. The file shows the claim was submitted with an invalid national clinical trial number for the TAVR procedure to be considered for payment. Therefore, we decided that the Plan does not have to pay for CPT code 33361 provided on October 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility services provided on December 6, 2019.You asked the Plan to pay for Skilled Nursing Facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted revenue code was missing a valid HIPPS code.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Skilled Nursing Facility serviceshave not been met. The documentation submitted does not include sufficient information to verify revenue code 0636. This revenue code requires a HCPCS code to verify what vaccine was administered. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility services provided on December 6, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on October 31, 2019 to
December 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you believe this was denied in error. The Plan
denied your request. The Plan says the member's primary care physician did not refer these services. The Plan
says that no prior authorization was obtained.
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 chiropractic services provided on October 31,
2019 to December 17, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approve Neulasta. You asked the Plan to pre-approve the Neulasta. You say that the records provided support the need for the drug being requested.The Plan denied your request. The Plan says that medical necessity criteria have not been met because the regimen is low risk for developing febrile neutropenia.The Plan says that the documentation provided does not support that the enrollee has met the standards for coverage of the requested drug.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 Neulasta. Our reviewer says that the documentation provided supports that the Neulasta is medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee is heavily pretreated with several prior lines of chemotherapy, boosting risk of an intermediate risk regimen such as vinorelbine to high risk of neutropenic fever. The documentation supports the Neulasta is safe and effective forthe enrollee. The requested use of Neulasta is FDA-approved for the enrollee's diagnosis.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 Neulasta have not been met.Therefore, we decided that the Plan has to pre-approve Neulasta.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services 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. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require ongoing skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. Your functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment beyond the last covered day. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" beyond the last covered day. As a practical matter you do not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee surgery provided on September 17, 2019.
You asked the Plan to waive the coinsurance for the knee surgery. You say that you have seen this provider before and the prior claim was processed as in-network. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 30% coinsurance per visit for out-of-network outpatient surgery. The enrollee has been asked to pay $541.67 which is 30% of the allowed amount for the knee surgery. The allowed amount is $1,805.55. ($1,805.55 x 30% = $541.67). The knee surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the knee surgery provided on September 17, 2019.
Our decision is only about the September 17, 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), and electronic connection between wheelchair controller and two or more power seating system motors (E2311).You asked the Plan to pre-approve an expandable controller, harness for upgrade to expandable controller, and electronic connection between wheelchair controller and two or more power seating system motors. You say that the requested 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 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 denying the request to pre-approve an expandable controller, harness for upgrade to expandable controller, and electronic connection between wheelchair controller and two or more power seating system motors. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found these accessories/items are not necessary and are convenience items. You are performing mobility-related activities of daily living (MRADL's) with a standard power option. As such, this request is 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 an expandable controller, harness for upgrade to expandable controller, and electronic connection between wheelchair controller and two or more power seating system motors have not been met.Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), and electronic connection between wheelchair controller and two or more power seating system motors (E2311)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that you are asking for payment for insoles that you purchased. You stated that the inserts have been helping tremendously with your pain and walking abilities. You say that you were told by a Plan representative that the orthotics would be covered if your Doctor said that they were medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecooled radiowave treatment (RFA to right knee) for the enrollee.You asked the Planto pre-approvethe treatment. You say that this is medically necessary.The Plandenied your request. The Plansaysthis procedure is still being studied in clinical trials for efficacy in the treatment of knee pain due to osteoarthritis, or in the setting of replacing or significantly deferring total knee arthroplasty.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 denying the request to pre-approve the treatment. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational procedure that is the subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable or 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 the treatment have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecooled radiowave treatment (RFA to right knee) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on February 19, 2020.You asked the Plan to waive the copayment forthe laboratory work. You say that you believe the copayment should be waived because you have THP.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 $5 copayment for Medicare-covered laboratory tests. You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work you received included lipid panel, a comprehensive metabolic panel, thyroid stimulating hormone, and an automated hemogram.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe laboratory work provided on February 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the hand (73130) provided January 5, 2020.You asked the Plan to pay for the x-ray. You say that the service was medically necessary.The Plan denied your request. The Plan says the claim was 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.We find that CPT code 73130 is not supported in the medical record. Specifically, the diagnosis code on the claim indicates the fracture was on the right side, however the x-ray was coded for the left side. The CPT modifier used denotes the incorrect laterality. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met.Therefore, we decided that the Plan does not have to pay for an X-ray of the hand (73130) provided January 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after May 20, 2020.You asked the Plan to pre-approvecontinued SNF care. You say that the enrollee is not well enough to be released from the SNF.The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while the enrollee does have skilled nursing needs, these needs are not on adaily basis. The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after May 20, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Procrit.You asked the Plan to pre-approve Procrit. You say that the enrollee requires this medication to treat anemia.The Plan denied your request. The Plan says the denial of authorization for Procrit is correct, because the Plan requires a trial of Retacrit before it will approve Procrit.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 Procrit. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Procrit. Our physician reviewer found the documentation does not indicate that the enrollee has had prior treatment, contraindication, or intolerance to the Plan's preferred drug of Retacrit. The documentation does not show that Retacrit would likely be less effective and/or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met.Therefore, we decided that the Plan does not have to pre-approve use of Procrit.