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

We decided that the Plan does not have to pre-approve Repatha Sure injection services.
You asked the Plan to pre-approve the Repatha Sure injection services. You say that the enrollee has a diagnosis of peripheral artery disease, coronary artery disease, peripheral neuropathy, nephropathy, fatty liver, poor wound healing, and retinopathy. You say that the enrollee does not take statins due to too many liver problems. You say that, on Repatha, the enrollee's LDL went from 173, to 143, to 65. You say that the lipid panel results and the chart notes were submitted to support this request. The Plan denied your request. The Plan says the drug in question is not covered under the enrollee's contract under any normal circumstances.
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 Repatha Sure injection services.
Benefits for the Repatha Sure injection services 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 waive the copayments for laboratory services provided on January 9, 2020 and January 10, 2020.
You asked the Plan to waive the copayments for laboratory services. You say that you disagree with the charges because you feel that you acquired an infection at a hospital facility. 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 laboratory services. You received laboratory services on January 9, 202 and January 10, 2020 for a total of 2 services. Therefore, you are responsible to pay a $10 copayment per each date of service. The total amount you owe is $20. You have been asked to pay the total copayment amount of $20 for laboratory services. Laboratory services fall 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 laboratory services provided on January 9, 2020 and January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the ankle foot orthosis, and the shoulder-elbow-wrist-hand orthosis provided by provider on August 27, 2019.You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the ankle foot orthosis (L1971), and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says a review of the documentation did not contain evidence of a relationship with the ordering physician.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, the ankle foot orthosis, and the shoulder-elbow-wrist-hand orthosis provided by provider on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960) provided August 7, 2019.You asked the Plan to pay forthe SEWHO. You say that the doctor saw that it was medically necessary for the management of the enrollee's chronic plan and joint stability; and signed off on the brace. Please reconsider the claim for payment.The Plan denied your request. The Plan says the records provided do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that a face-to-face encounter is required with documentation that includes information supporting that the beneficiary was evaluated or treated for a condition that supports the DME item(s) ordered We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SEWHO have not been met.Therefore, we decided that the Plan does not have to pay forthe shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960) provided August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral ankle foot orthoses (L1971) provided to the enrollee on August 5, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says there are no recent records available.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. We reviewed records sent by the doctor from 2013 and they show the enrollee had right-sided Achilles tendon pain and have had been given a walking boot previously. No recent evaluation for ankle pain or the need for bracing was received.Therefore, we decided that the Plan does not have to pay forbilateral ankle foot orthoses (L1971) provided to the enrollee on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies.You asked the Plan to pay for incontinence supplies. You say that you need this underwear at bedtime.The Plan denied your request. The Plan says this is not covered by Medicare.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Baclofen tablet, 10mg.You asked the Plan to pre-approveBaclofen. The Plan denied your request. The Plan says your policy does not include Part D prescription drug coverage. The Plan says drugcoverage is limited to Medicare Part B covered drugs. The Plan also says Baclofen is not a drug covered under 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-approveBaclofen tablet, 10mg.Benefits for Baclofenmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 9, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four monitoring is considered a bundled procedure and the cost is included in the cost of the primary procedure.
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 find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary procedure and it is not eligible for separate payment consideration. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea powered pressure reducing air mattress.You asked the Planto pre-approvethe mattress. You say that this is medically necessary.The Plandenied your request. The Plansaysa replacement air loss mattress can be received if the current mattress is no longer working, and the mattress is continued to be needed.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 mattress. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you require the requested mattress or a new mattress. There is no evidence that the current mattress requires replacement or cannot meet your medical needs. The PT evaluation and records indicate that you have the appropriate mattress currently and the documentation does not support that you require a replacement mattress or the specific brand of mattress requested for your 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 the mattresshave not been met.Therefore, we decided that the Plandoes not haveto pre-approvea powered pressure reducing air mattress.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95999 provided on August 9, 2019.
You asked the Plan to pay for CPT code 95999. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says CPT code 95999 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 95999 is unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train
of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is
inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring.
There is no separate code for train of four monitoring. Based on this information, we decided that Medicare
rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to
pay for CPT code 95999 provided on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 2, 2020.You asked the Plan to pay for the dental services. You say that according to your optional supplemental comprehensive dental plan, these services should be covered.The Plan denied your request. The Plan says the limited oral evaluation 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, the limited oral evaluation is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says the documentation provided
did not indicate the need for the billed supplies.
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 medical records do not support medical necessity for the
orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833)
and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay
for the knee orthoses and suspension sleeves
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epidural Steroid Injections (64483, 64493, 64484, 64494).
You asked the Plan to pre-approve the injections. You say that the requested services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had injections in the past but there is no documentation of the degree and duration of pain relief. There is no documentation of recent physical therapy. He has not had an adequate trial of conservative 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Epidural Steroid Injections (64483, 64493, 64484, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe direct skilled nursing services of a registered nurse services coded G0299 provided on September 19, 2019 to September 24, 2019.You asked the Plan to pay forthe direct skilled nursing services of a registered nurse services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed with an incorrect type of bill code.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 G0299 is direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes.We find that CPT code G0299 is not supported in the medical record. Specifically, the bill type is inconsistent with the place of service billed. Based on this information, we decided that Medicare rules for coverage of the direct skilled nursing services of a registered nurse services have not been met. Therefore, we decided that the Plan does not have to pay forthe directskilled nursing services of a registered nurse services coded G0299 provided on September 19, 2019 to September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 12, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that this provider told you that they accept this Plan and are in-network.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 forthe medical services provided on June 12, 2019 by an outof network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe presbyopia correcting function of intraocular lenses provided on December 16, 2019 and December 26, 2019.You asked the Plan to pay forthe presbyopia correcting function of intraocular lenses. You say that you paid for these lenses in advance.The Plan denied your request. The Plan says the services received are not a covered benefit.The Plan covers all items that Medicare covers.Medicare rules saythat if an enrollee receives anonconventional IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the nonconventional IOL and a conventional IOL. While a nonconventionalIOL may be appropriate for you, neither the Plan nor Medicare covers the nonconventionalfeature of an IOL.Therefore, we decided that the Plan does not have to pay forthe presbyopia correcting function of intraocular lenses provided on December 16, 2019 and December 26,2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483 provided on September 11, 2019.You asked the Plan to pay forthe drug testing. 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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include lab results for 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483 provided on September 11, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveinitiation of Part A-covered skilled nursing facility (SNF) care.You asked the Planto pre-approvethe SNF care. You say that it is felt that daily therapy would be beneficial to allow the enrollee to discharge to the assisted living portion of the facility.The Plandenied your request. The Plansaysthe enrollee's condition is not such that daily skilled services are required.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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided ata lower level of 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 the SNF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveinitiation of Part A-covered skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral for vascular surgery (99204).
You asked the Plan to pre-approve the referral. You say that you have varicose veins that you fear will pop when walking. The Plan denied your request. The Plan says that the record does not include any clinical documentation of bleeding variscosities, ulcers, thrombophlebitis, conservative therapies or diagnostic testing.
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 referral. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have complaints of leg pain as well as a history suggestive of foot pain and difficulty walking. Your arterial perfusion is unknown nor is the status of her lower extremity venous system. Vascular consultation would be appropriate. 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 referral have been met. Therefore, we decided that the Plan has to pre-approve a referral for vascular surgery (99204).