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

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because the enrollee only tests 2 times per day and is not using insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 continuous glucose monitor. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested continuous glucose monitor. Our physician reviewer found the enrollee has type 2 diabetes managed with oral medications. She does not use insulin to manage diabetes. No discussion of diet management is included in the records. The documentation does not show that the continuous glucose monitor will be used in place of a blood glucose monitor for the enrollee making diabetes treatment decisions. Therefore, the continuous glucose monitor is not 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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora Myocardial SPECT imaging test (78452) provided December 4, 2019.You asked the Plan to waive the copayment forthe stress test. You say that the copaymentshould be waived.The Plan denied your request. The Plan says they have removed a $117.04 coinsurance that was incorrectly applied, but the $200 copayment is correct.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 for Advanced Imaging. You have been asked to pay a $200 copayment for the stress test. The stress test falls within the Advanced Imaging 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 acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora Myocardial SPECT imaging test (78452) provided December 4, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on August 27, 2019.You asked the Plan to waive the copayment for an ultrasound of the heart. You say that you did not receive services in an outpatient hospital facility and should only owe $25.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 an $85 copayment for basic radiological services provided in an outpatient hospital facility. The record shows that you received an ultrasound of the heart at an outpatient hospital facility on August 27, 2019. Therefore, you are responsible to pay the $85 copayment. You have been asked to pay an $85 copayment for an ultrasound of the heart. An ultrasound of the heart 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 copayment for an ultrasound of the heart provided on August 27, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a psychiatry office visit (99204), psychiatric diagnostic evaluation (90791), psychiatric diagnostic evaluation with medical services (90792), and psychotherapy visit, 60 minutes (90838) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the psychiatry office visit, psychiatric diagnostic evaluation, psychiatric diagnostic evaluation with medical services, and psychotherapy visit, 60 minutes. You say that you need to go to UC San Diego for these services since they will cover the cost of the coinsurance. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a psychiatry office visit (99204), psychiatric diagnostic evaluation (90791), psychiatric diagnostic evaluation with medical services (90792), and psychotherapy visit, 60 minutes (90838) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition supplies (B4220, B4185, B4224, B4193) provided on September 12, 2019.
You asked the Plan to pay for parenteral nutrition supplies. You say that this was medically necessary. The Plan denied your request. The Plan says required information was not submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery slip included in the file does not contain a carrier information and is not signed. Therefore, we decided that the Plan does not have to pay for parenteral nutrition supplies (B4220, B4185, B4224, B4193) provided on September 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEntresto tablets.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveEntresto tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a procedural mask and isopropyl alcohol.
You asked the Plan to pre-approve the procedural mask and the isopropyl alcohol. You say that your physician urged you to get masks and gloves because you are in the high risk category due to your age and health. The Plan denied your request. The Plan says over-the-counter items purchased from pharmacies or other retailers will not be covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The Plan offers a benefit for over-the-counter items when purchased through the vendor. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. While the items in dispute are not covered by Medicare, the Plan does have a supplemental benefit for over-the-counter items. This benefit is limited to items supplied through the specified vendor. The records show that you are requesting coverage for items through a supplier that is not the specified vendor. Therefore, we decided that the Plan does not have to pre-approve a procedural mask and isopropyl alcohol.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 12, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 92512 and 92520.
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 92512 is nasal function studies (eg, rhinomanometry). The definition of code 92520 is laryngeal function studies (ie, aerodynamic testing and acoustic testing). We find that CPT codes 92512 and 92520 are not supported in the medical record. Specifically, there are no medical records for the date of service to support that these codes were performed. 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 August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtained authorization. The Plan denied your request. The Plan says 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 skilled nursing services provided on November 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on November 30, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you needed a tetanus shot and your physician's office was closed. You say that you were not aware of a copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for each Medicare-covered urgently needed care visit. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 for the urgent care visit provided on November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on December 11, 2019.You asked the Plan to waive the copayment for an office visit. You say that you had to have your blood pressure re-checked and were told that you would not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for each visit with a primary care provider. You had an office visit on December 11, 2019. The record shows that your annual wellness visit was on December 4, 2019. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An 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 an office visit provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (CPT D2950) and a prefabricated post and core (CPT D2954).You asked the Plan to pre-approve the core buildup and the prefabricated post and core. The Plan denied your request. The Plan says the services being requested are not covered by Medicare or under your health plan contract.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 pre-approve core buildup (CPT D2950) and a prefabricated post and core (CPT D2954).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist.You asked the Plan to pre-approve these services. You say that you have a history of referrals to this provider.The Plan denied your request. The Plan says the services are available from network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that your doctor cannot deny any medical services that were essential for patient health treatment. The Plan denied your request. The Plan says 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 physician services provided on May 15, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on November 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the hip (73502) provided November 14, 2019.You asked the Plan to waive the copayment for the x-ray. You say that the cost of the x-ray should be included in the surgery.The Plan denied your request. The Plan says the x-ray is a separate service from the surgery and the proper copayment was 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 $40 copayment for Diagnostic Imaging. You have been asked to pay a $40 copayment for the x-ray. The x-ray falls within the Diagnostic Imaging 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 an x-ray of the hip (73502) provided November 14, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral nutrition supplies rendered on September 24, 2019 to October 23, 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 there is no valid proof of delivery. The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 enteral nutrition supplies rendered on September 24, 2019 to October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cervical/Thoracic Interlaminar Epidural.
You asked the Plan to pre-approve a Cervical/Thoracic Interlaminar Epidural. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a series of three (3) epidural injections may be repeated at six (6) month intervals (assuming there was a positive response as defined by the ASIPP guidelines) to the first series of three (3) injections. 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 Cervical/Thoracic Interlaminar Epidural. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee had an epidural steroid injection in March 2020 but there is no documentation as to the degree and duration of pain relief after that injection. Therefore, the documentation requirement is not met and therefore, the procedure is deemed not medically reasonable or necessary at this point in time. 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 Cervical/Thoracic Interlaminar Epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cervical/Thoracic Interlaminar Epidural.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires. The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 3, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on January 3, 2020.