Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee does not need continued skilled services.
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 the enrollee does not have identifiable skilled nursing or therapy needs and does not meet severity of illness or intensity of service criteria for 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 pay for a Tenex percutaneous ultrasonic tenotomy (27299, 76942) provided on August 13, 2019.
You asked the Plan to pay for a Tenex percutaneous ultrasonic tenotomy. You say that this was medically necessary. The Plan denied your request. The Plan says this is experimental.
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 pay for a Tenex percutaneous ultrasonic tenotomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this procedure for this enrollee's medical condition as safe and effective. This procedure would be considered investigational for this enrollee's medical 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 a Tenex percutaneous ultrasonic tenotomy have not been met. Therefore, we decided that the Plan does not have to pay for a Tenex percutaneous ultrasonic tenotomy (27299, 76942) provided on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder orthosis and lumbar sacral orthosis provided to the enrollee on December 9, 2019.You asked the Plan to pay forthe orthoses. The Plan denied your request. The Plan says that a review of the submitted documentation does not contain evidence of a prior Telemedicine or 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 noncovered visit arelikewise noncovered.Therefore, we decided that the Plan does not have to pay forthe shoulder orthosis and lumbar sacral orthosis provided to the enrollee on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Oximeter device (E0445).You asked the Plan to pre-approvean Oximeter device. You say that the item is necessary.The Plan denied your request. The Plan says the requested item is a non-covered item. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that Oximeters (E0445) and replacement probes (A4606) will be denied as non-covered because they are monitoring devices that provide information to physicians to assist in managing the beneficiary's treatment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Oximeter device have not been met.Therefore, we decided that the Plan does not have to pre-approvean Oximeter device (E0445).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on November 20, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 13 and a root canal (D3320) for tooth # 13.
You asked the Plan to pre-approve the core build up. You say that the core build up is medically necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 13 and a root canal (D3320) for tooth # 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the one crown provided on January 23, 2020 and to pay for the additional crown and occlusal guard provided on January 29, 2020 by an OON provider.
You asked the Plan to pay for the occlusal guard and crowns. You say that the crown provided on January 23, 2020 should have been covered at 25%. The Plan denied your request. The Plan says occlusal guard is not a covered benefit. The Plan also says that the crown provided on January 29, 2020 exceeds the benefit allowance for calendar year 2020.
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, occlusal guard is not among those covered under this benefit. The contract clearly states that crowns are limited to one procedure per calendar year and you are responsible for the difference between the billed amount and allowed amount when the service is received OON. The record shows that you received a crown on January 23, 2020, provided by an OON provider, and your crowns benefit was then exhausted. Therefore, we decided that the Plan does not have to pay more for the one crown provided on January 23, 2020 and to pay for the additional crown and occlusal guard provided on January 29, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for aortography provided on February 20, 2019.
You asked the Plan to pay for aortography. You say that you are appealing with the operative report. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered when billed with this diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that procedure code 75630 is only covered when billed with certain, specific diagnosis codes that do not include I70.262. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aortography have not been met. Therefore, we decided that the Plan does not have to pay for aortography provided on February 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on February 14, 2019 to February 15, 2019.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized.
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 radiology services provided on February 14, 2019 to February 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bevacizumab injection coded J9035 and the chemotherapy administration services coded 96413 provided on November 27, 2019.
You asked the Plan to pay for the bevacizumab injection and the chemotherapy administration 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code J9035 is Injection, bevacizumab, 10 mg. The CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. We find that CPT codes J9035 and 96413 are not supported in the medical record. Specifically, the documentation does not support that injection, bevacizumab, 10 mg was administered. Therefore, code 9J9035 is not supported by the documentation. Also, the documentation does not support that chemotherapy administration, intravenous infusion technique; up to 1hour, single or initial substance/drug was performed. Therefore, code 96413 is not supported by the documentation. Based on this information, we decided that Medicare rules for coverage of the bevacizumab injection and the chemotherapy administration services have not been met. Therefore, we decided that the Plan does not have to pay for the bevacizumab injection coded J9035 and the chemotherapy administration services coded 96413 provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 18, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you are appealing the cost sharing applied to this claim. 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 per specialist office visit. You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 18, 2020.
Your complaint about the provider's incompetence is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and the laboratory work provided on February 12, 2020.
You asked the Plan to waive the copayments for the specialist office visit and laboratory work. You say that you received a letter from the provider that all of services were covered. 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 $50 copayment for each in-network Medicare-covered visit with a specialist and a $20 copayment per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay a $50 copayment for the specialist office visit and a $20 copayment for the laboratory work. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 visit and the laboratory work provided on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 5, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 5, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvereplacement socket and K3 prosthesis. You asked the Plan to pre-approvethe prosthesis. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says that request for a replacement socket does not meet Medicare criteria as reasonable and necessary. The K3 prosthesis exceeds the enrollee's need and does not meet Medicare criteria as reasonable and 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 prosthesis. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee is status post right above knee amputation on 5/7/19. His current initial prosthesis is a K1 level prosthesis which includes only transfer activities. He is using this prosthesis at a level that exceeds its componentry and it is reportedly holding him back from properly ambulating. His functional score is consistent with a functional K3 level. The replacement socket and K3 prosthesis are indicated due to the documented functional need changes requiring a higher functional level prosthesis. He has the demonstrated potential for K3 functional ability. A replacement socket is indicated to support the new prosthesis. Therefore, the medical records provided meet the requirements listed in the LDC/PIM for Medicare coverage. 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 prosthesis have been met.Therefore, we decided that the Plan has to pre-approvereplacement socket and K3 prosthesis. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit (11043 and 99336). You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says the member sought non-emergent/urgent services on his own with a non-contracting provider and did not allow the PCP to request approval from the Health Plan which would have advised him where to seek the 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 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 26, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring System.You asked the Plan to pre-approvea continuous glucose monitor. You say that you need a CGM. The Plan denied your request. The Plan says you are not insulin injecting three or more times a day and do not have a visual or dexterity impairment. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows you are not insulin treated with three or more daily injectionsand do not test four or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the MRI provided on February, 14, 2020.
You asked the Plan to reduce the copayment for the MRI. You say that this is too much money and you would like the copayment to be reduced to a $75 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 a $200 copayment per provider, per date of service for complex radiology (MRI/MRA, CT scans, nuclear cardiology studies). You have been asked to pay a $200 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 reduce the copayment for MRI provided on February, 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each (L3020).You asked the Plan to pre-approve the foot orthotic.. You say that the durable medical equipment is 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 pre-approve foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each (L3020).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on December 11, 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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that modifier -77 is used to indicate that another physician repeated a procedure or service in a separate operative session on the same day. We looked at the file and Medicare rules. The file shows that the provider submitted a claim for procedure code 70450 with modifier -77. There is no documentation that the procedure was provided by another physician. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on December 11, 2019.