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

We decided that the Plan does not have to pre-approve Hydroxyz Tablets.You asked the Plan to pre-approve Hydroxyz Tablets. You say that this medication is medically necessary for treatment of the member's condition. The Plandenied your request. The Plan says drug coverage is limited only to those drugs covered under the member's medical 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 Hydroxyz Tablets. Benefits for Hydroxyz Tablets may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (1851) and sleeve (L2397) provided July 15, 2019.You asked the Plan to pay forthe orthoses. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of aMetropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forknee orthosis (1851) and sleeve (L2397) provided July 15, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the back brace fitting provided on October 22, 2019.You asked the Plan to waive the copayment forthe back brace fitting. You say that you were unaware there would be a copayment for the fitting. You say were only advised for the cost of the brace. 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 $15 copayment for each Medicare-covered outpatient rehabilitation service, treatment, or evaluation. You have been asked to pay a $15 copayment for the back brace fitting. The back brace fitting falls within the "Outpatient rehabilitation services" 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 forthe back brace fitting provided on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no support for this service.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration is experimental and more research is needed. 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 pre-approve bone marrow aspiration for bone grafting for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services coded 97597 provided on May 21,
2019.
You asked the Plan to pay for the debridement services. 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 supported by the
documentation.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 97597 is 3. You billed 26 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the debridement services have not been met.
Therefore, we decided that the Plan does not have to pay for the debridement services coded 97597 provided on
May 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Ambulance (A0429) and Emergency Room (99282) services provided September 3, 2019 
You asked the Plan to waive the copayments for the ambulance and emergency room services. You say that you were sent to the Hospital by the police department and should not be responsible for the copayment. The Plan denied your request. The Plan says the correct cost sharing has been applied.
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 $90 copayment for the Emergency Room and a $250 copayment for the ambulance. You have been asked to pay a $90 copayment for the Emergency Room and a $250 copayment for the ambulance. The ambulance and emergency room services falls within the Emergency Care and Ambulance Services 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 Ambulance (A0429) and Emergency Room (99282) services provided September 3, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) knee orthosis (L1851) and sleeve (L2397) provided August 21, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) knee orthosis (L1851) and sleeve (L2397) provided August 21, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99232) provided on September 1, 2019.You asked the Plan to pay for the subsequent hospital care. You say that these services were rendered by separate providers with different specialties. The Plan denied your request. The Plan says that CPT code 99232 cannot be paid because the rendering providers are in the same group and have the same specialty.The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.We find that CPT code 99232 is supported in the record. Specifically, the rendering providers have different specialties. The billing provider's specialty is Internal Medicine Pulmonary Medicine. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have been met. Therefore, we decided that the Plan has to pay for subsequent hospital care (99232) provided on September 1, 2019. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on August 20, 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant provided on October 8, 2019.
You asked the Plan to pay for the endosteal implant. You say that you would like some help from your insurance Plan to pay for this service. The Plan denied your request. The Plan says you do not have routine dental benefits. The Plan also says that you were notified prior to the services being provided that you did not have dental coverage, and chose to have the services rendered knowing this.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hip orthosis and addition to lower extremity provided on September 3, 2019.You asked the Plan to pay forthe hip orthosis and addition to lower extremity. 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 supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe hip orthosis and addition to lower extremity provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve sacroiliac joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that based on the clinical information submitted, the injection is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve the injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the health plan is mistaken in that the enrollee has not had a prior SI joint injection. The statement that intra-articular steroid injection is not indicated here is wrong. This bilateral injection will confirm the diagnosis, and the use of steroids should provide long-lasting pain relief. If the block is negative then alternate pain generators should be sought. The requested procedure is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pre-approve sacroiliac joint injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 6, 2019 to September 16, 2019.
You asked the Plan to pay for the orthoses. 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 6, 2019 to September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on September 11, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on September 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for aquatic therapy with therapeutic exercises (97113)provided on August 2, 2019 to August 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for aquatic therapy with therapeutic exercises. You say that the concept underlying the Plan's requirement of prior authorization is to ensure that the company is only paying for medically necessary care. You enclosed medical documentation to support the medical necessity of the service rendered. You saythis is not a case in which the physician's judgement for treatment was so plainly unreasonable or contrary to good medical practice that coverage should be denied.The Plan denied your request. The Plan says the provider is a non-network provider with the member's health plan, and another non-network provider with the member's health plan referred the member for services. The member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers whenpossible 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 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 foraquatic therapy with therapeutic exercises (97113) provided on August 2, 2019 to August 26, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shingles vaccine (90750) provided on May 23, 2019.You asked the Plan to pay forthe shingles vaccine. You say that you would like reconsideration as you do not believe you should be liable for this charge.The Plan denied your request. The Plan says this vaccine is covered under the Medicare Part D benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to pay forthe shingles vaccine (90750) provided on May 23, 2019.Benefits for the shingles vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OneTouch Ultra Blue Test Strip for the enrollee.You asked the Plan to pre-approvethe strips. You say that this is medically necessary.The Plan denied your request. The Plan has other preferred test meters and test strips.The Plan must follow Medicare rules. Medicare rules say that plans can specify preferred brands of durable medical equipment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pre-approve the strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the One Touch Ultra Blue Test Strip is not a preferred strip for the plan. There is no medical reason documented that the member is medically unable to use the the plan preferred meters. The review has determined that there is no medical necessity for the specific brand of strips.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 strips have not been met.Therefore, we decided that the Plan does not have to pre-approvethe OneTouch Ultra Blue Test Strip for theenrollee.
Appeal type: Lab
Decision: Unfavorable

You asked the Plan to pay for the outpatient hospital 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on June 25, 2019.