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

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a medical eye exam (92014) and a fundus photograph (92250) provided on February 10, 2021.
You asked the Plan to pay for a medical eye exam and a fundus photograph. You say that the enrollee was referred by his primary care physician (PCP). The Plan denied your request. The Plan says that services were provided by an out-of-network provider without prior authorization.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for a medical eye exam and a fundus photograph by a contract provider. The records show that the enrollees in-network PCP referred the enrollee and advised that an authorization was not required. The file does not show that the plan provided notice that a medical eye exam and a fundus photograph would not be covered. Under Medicare rules, this means a medical eye exam and a fundus photograph is considered approved by the plan. Therefore, we decided that the Plan has to pay for a medical eye exam (92014) and a fundus photograph (92250) provided on February 10, 2021.
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 pre-approve a C-Leg microprocessor-controlled knee joint.
You asked the Plan to pre-approve a C-Leg microprocessor-controlled knee joint. You say that the requested C-Leg microprocessor-controlled knee joint is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested C-Leg microprocessor-controlled knee joint.
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 a C-Leg microprocessor-controlled knee joint. Our reviewer says that the enrollee does not meet criteria for the requested C-Leg microprocessor-controlled knee joint. Our physician reviewer found the requested C-Leg microprocessor-controlled knee joint is not medically necessary as the request exceeds the enrollee's medical need. The documentation from the physician does not support that the enrollee requires the C-leg over an alternative non microprocessor K3 mechanical knee. 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 C-Leg microprocessor controlled knee joint have not been met. Therefore, we decided that the Plan does not have to pre-approve a C-Leg microprocessor-controlled knee joint
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 12, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 pay for the drug testing services provided on November 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide (HHA) visits.
You asked the Plan to pre-approve the HHA visits. You say that you need assistance in the home due to your conditions, and because you are legally blind. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 HHA visits. Our reviewer says that the coverage criteria for the requested HHA services are not met. Our physician reviewer found the enrollee is a male with chronic pain who is legally blind. A home safety evaluation was performed in April 2021, and a request for HHA services for assistance with daily living activities was made. There is no evidence that the enrollee is receiving, or requires, skilled nursing or therapy services in the home. HHA services are only covered when provided along with skilled nursing or therapy. 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 HHA visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) visits.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the payment of ambulance service, basic life support, emergency transport (A0429), and the ground mileage (A0425) provided on June 18, 2021.
You asked the Plan to pay for the transportation services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the transportation was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 transportation services. Our reviewer says that the emergency transportation was medically necessary. Our physician reviewer found the documentation indicates that the enrollee was hemodynamically stable with stable vital signs. The reviewer found that the enrollee's presenting symptoms met prudent layperson criteria for emergency care. Therefore, the reviewer found that the emergency transportation services were 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 transportation services have been met. Specifically, the file indicates that the enrollee's presenting symptoms met prudent layperson criteria for emergency care. Therefore, we decided that the Plan has to pay for the payment of ambulance service, basic life support, emergency transport (A0429), and the ground mileage (A0425) provided on June 18, 2021.
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: 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity weakness and a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vagifem.
You asked the Plan to pre-approve Vagifem. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Vagifem.
Benefits for Vagifem 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 lab work provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 had network providers available who could have provided 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 lab work provided on April 7, 2021 by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) and oral hygiene instructions (D1333) provided April 13, 2021.

You asked the Plan to pay for the comprehensive periodontal exam and oral hygiene instructions. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) and oral hygiene instructions (D1333) provided April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 20, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve a Freestyle Libre. You say that the requested item is a medical need for the enrollee. The Plan denied your request. The Plan says rules for continuous glucose monitors have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve balloon sinuplasty for frontal and sphenoid sinuses.
You asked the Plan to pre-approve balloon sinuplasty for frontal and sphenoid sinuses. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 balloon sinuplasty for frontal and sphenoid sinuses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found although the enrollee suffers from chronic sinusitis symptoms, her computed tomography (CT) did not show evidence of disease in the frontal or sphenoid sinuses. The Academy of Otolaryngology does not support performing sinus procedures on sinuses that do not have disease on the CT scan. Therefore, she does not meet criteria for a surgical procedure of the frontal or sphenoid sinuses. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of balloon sinuplasty for frontal and sphenoid sinuses have not been met.
Therefore, we decided that the Plan does not have to pre-approve balloon sinuplasty for frontal and sphenoid sinuses.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone cypionate 100 mg/ml injection.
You asked the Plan to pre-approve the injection. You say that the requested injection is necessary. The Plan denied your request. The Plan says drugs, such as testosterone, when not administered from the doctor's stock and supplied by the pharmacy are covered under the Medicare Part D benefit and not Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve testosterone cypionate 100 mg/ml injection.
Benefits for the injection 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for durable medical equipment provided by a participating provider on August 31, 2020.
You asked the Plan to waive the copayment for durable medical equipment. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $611.40. The total amount you are being asked to pay is $122.28 ($611.40 x 20% = $122.28). The correct coinsurance has been applied to the equipment that was provided. Durable medical
equipment falls within the durable medical equipment/in-network 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 durable medical equipment provided by a participating provider on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) injections.
You asked the Plan to pre-approve SI injections. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 SI injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physical exam tests documented do not support the diagnosis, e.g. negative sacral compression and thrust test. Therefore, the request is considered 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 SI injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) injections.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on September 8, 2020.
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 95957, 95907, and 95885 are not supported.
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 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). The definition of code 95907 is nerve conduction studies; 1-2 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). We find that CPT codes 95957, 95907, and 95885 are not supported in the medical record. Specifically, there is no documentation of digital EEG analysis to support code 95907. There is no documentation of 1-2 nerve conduction studies to support code 95907. There is no documentation of needle electromyography to support code 95885. 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 testing services rendered on September 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from March 15, 2020 to April 13, 2020.
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 billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with an appropriate revenue code. We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid revenue 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 March 15, 2020 to April 13, 2020.