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

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 25, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 remains not supported. The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on November 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you cannot go home because your cannot take care of yourself. The Plan denied your request. The Plan says that continuation of SNF is not reasonable and medically necessary you are refusing to participate in skilled therapies.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on November 4, 2019. You asked the Plan to pay for the wound care supplies. You say that the wound care supplies were medically necessary. The Plan denied your request. The Plan says any DME furnished to inpatients in a covered Part A stay is included in the SNF PPS rate. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that the wound care supplies were used in a SNF. Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on January 15, 2020.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the enrollee had a shoulder-elbow-wrist-hand orthosis from a different provider and it is still under reasonable useful lifetime.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The enrollee's orthosis is still within the 5-year RUL and the documentation submitted does not show that the shoulder-elbow-wrist-hand orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTadalafil 5mg tablets.You asked the Plan to pre-approveTadalafil. You say that the medication is medically necessary.The Plan denied your request. The Plan says coverage for this medication is not available under the Part B 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-approveTadalafil 5mg tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing services provided to the enrollee on July 9, 2019.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says Medicare pays for limited services via telecommunications.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 ProfessionalShortage 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 programand 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 forthe genetic testing services provided to the enrollee on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 30, 2019.
You asked the Plan to pay for drug tests. You say that the only report you have on file is the requisition form from the referring doctor. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records to support these tests.
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 April 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered to you on November 7, 2019.
You asked the Plan to waive the copayment for these services. You say that the services were an annual wellness visit and should have no copayment. The Plan denied your request. The Plan says the copayment was 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 $50 copayment for services obtained from an in-network specialist. Review of the file shows that you received specialist physician services on November 7, 2019. These services fall outside of the scope of an annual wellness visit. You have been asked to pay a $50 copayment for these services. These services fall within the services obtained from an in-network specialist 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 physician services rendered to you on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the knee scooter purchased on November 28, 2019.You asked the Plan to reimburse you forthe knee scooter. You say that the knee scooter was necessary for you to recover from an injury.The Plan denied your request. The Plan says the supplier is not enrolled in Medicare.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. We looked at the file and Medicare rules. Knee scooters are not covered by Medicare and the item at issue in this appeal was provided by a provider not certified by Medicare. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met.Therefore, we decided that the Plan does not have to reimburse you forthe knee scooter purchased on November 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD).You asked the Plan to pre-approvea HFCWOD. The Plan denied your request. The Plan says that you do not meet criteria for coverage.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that a HFCWOD is not medically reasonable and necessary in this case. The documentation does not reveal that you have cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high frequency chest wall oscillation device may be covered. The documentation does not indicate that you presently use a mechanical in-exsufflation device (E0482) and plan to continue to do so. The records do not show well-documented failure of standard treatments to adequately mobilize retained secretions. Our physician reviewer found that your condition does not meet Medicare criteria for a HFCWOD.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 HFCWOD have not been met.Therefore, we decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on December 9, 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 code G0480 is 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 G0480 is definitive drug testing, 1-7 classes. We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation does not include a lab report or lab results for definitive drug testing of 1-7 drug classes. 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 definitive drug testing rendered on December 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) services and
office visit rendered to you on November 10, 2019 and November 21, 2019.
You asked the Plan to waive the copayments for these services. You say that the services were not rendered.
The Plan denied your request. The Plan says the copayments were 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 $90
copayment per visit for emergency care and a $15 copayment for PCP visits received from a standard primary
care physician.
Review of the file shows that you had ER services on November 10, 2019. You have been asked to pay a $90
copayment for these services. These services fall within the emergency care 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.
The file shows that you had PCP services on November 21, 2019. You have been asked to pay a $15
copayment for these services. These services fall within the PCP 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 copayments for the emergency room (ER)
services and office visit rendered to you on November 10, 2019 and November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 15, 2019.
You asked the Plan to pay for the dental services. You say that the oral exam should be covered. You also say that your last oral exam was over 6 months prior to this date of service. The Plan denied your request. The Plan says oral exams are covered once every 6 months. The Plan also says the frequency limit has been exceeded.
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 and oral exams are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for an oral exam that you received on September 27, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown, panoramic x-ray, periodic oral evaluation, bitewings, first intraoral periapical x-ray, and two additional intraoral periapical x-rays provided by an OON provider on January 28, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says services provided by an OON or Non-contracted provider are not covered under your benefit program.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown, panoramic x-ray, periodic oral evaluation, bitewings, first intraoral periapical x-ray, and two additional intraoral periapical x-rays provided by an OON provider on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation provided to the enrollee on October 7, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare uses another code for the reporting of the services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and the rules. We find that CPT code 99255 is not valid for Medicare purposes under the physician fee schedule. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient consultation provided to the enrollee on October 7, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a robotic assist rehabilitation orthotic for an upper extremity (L8702).
You asked the Plan to pre-approve the robotic assist rehabilitation orthotic for an upper extremity. You say that the enrollee's prosthetic is wearing out and she needs a replacement. The Plan denied your request. The Plan says medical studies have not proven that the device being requested is helpful for treatment of the enrollee's health problem.
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 robotic assist rehabilitation orthotic for an upper extremity. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is status-post stroke and has a unilateral left upper extremity impairment without other impairing condition. The enrollee would be expected to be able to perform her essential activities of daily living using single arm techniques and adaptive equipment. Although the requested device is reported as having some utility in post-stroke rehabilitation in terms of facilitating recovery, it is not considered the standard of care. Further research is needed to determine whether this device offers a clinically significant benefit in comparison with conventional treatments. MyPro is considered investigational due to the lack of clinical evidence demonstrating an impact on improved health outcomes. 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 robotic assist rehabilitation orthotic for an upper extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve a robotic assist rehabilitation orthotic for an upper extremity (L8702).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ferumoxytol (iron) injections. You asked the Plan to pre-approve the iron injections. You say that this should be covered due to the enrollee's need for this injection. The Plan denied your request. The Plan says there is insufficient documentation of anemia or that oral iron has been tried and failed. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the iron injections. Our reviewer says that the documentation does not support the medical necessity of the proposed iron injections. Our physician reviewer found there is no documentation of anemia in this patient or why he is not a candidate for oral iron. Only a low ferritin and documentation that he has had IV iron in the past. There is not enough documentation to support that IV Iron is reasonable or medically necessary for this patient. 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 iron injections have not been met. Therefore, we decided that the Plan does not have to pre-approve ferumoxytol (iron) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intermittent urinary catheters and
lubricant provided on January 9, 2020.
You asked the Plan to waive the coinsurance for the intermittent urinary catheters and lubricant. You say that
you cannot afford this payment. The Plan denied your request. The Plan says that the claim processed 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 20%
coinsurance for prosthetic devices and medical supplies.
You have been asked to pay a 20% coinsurance for the intermittent urinary catheters and lubricant. The
intermittent urinary catheters and lubricant falls within the prosthetic devices and medical 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 coinsurance for the intermittent urinary catheters and lubricant
provided on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Decision DX-Melanoma test provided to the enrollee on September 5, 2019.You asked the Plan to pay for the test. You say that this is a covered Medicare benefit.The Plan denied your request. The Plan says the records were received and it was determined that this service was not medically necessary.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 the test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found NCCN Clinical Practice Guidelines in Oncology Cutaneous Melanoma, Version 2.2020 -April 09, 2020 states that prognostic gene expression profiling to differentiate melanomas at low versus high risk for metastasis may provide information on individual risk of occurrence, as an adjunct to standard AJCCstaging. However, the currently available prognostic molecular techniques should not replace pathological staging procedures, and the use of GEP testing to specific melanoma stage requires further prospective investigation in large, contemporary data setsof unselected patients.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 test have not been met.Therefore, we decided that the Plandoes not haveto pay forthe DecisionDX-Melanoma test provided to the enrollee on September 5, 2019.