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

We decided that the Plan does not have to pay for the medical supplies provided on December 6, 2019.
You asked the Plan to pay for the medical supplies. 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.
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or
hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we
decided that the Plan does not have to pay for the medical supplies provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy
procedures (D0431) and gingival irrigation - per quadrant (D4921) provided on January 6, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the
plan.
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. The services are not listed in your EOC as a covered benefit; therefore,
the services are not covered. Therefore, we decided that the Plan does not have to pay for adjunctive prediagnostic
test that aids in detection of mucosal abnormalities including premalignant and malignant lesions,
not to include cytology or biopsy procedures (D0431) and gingival irrigation - per quadrant (D4921) provided
on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you recommended the orthotics for the enrollee
to reduce the enrollee's foot pain. The Plan denied your request. The Plan says this item is not a covered
benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for enrollee, neither Medicare nor the Plan provides coverage of
orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
January 13, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up
visit for a biopsy and you believe the copayment should be removed. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for each in-network specialist visit for Medicare-covered services.
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there
is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a
surgical procedure.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the specialist office visit provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic therapy services provided on December 26,
2019.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan
denied your request. The Plan says service not related to manual manipulation of the spine are not covered by
Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The records show that the services at issue were not
manual manipulation of the spine. Maintenance or therapy services provided by a chiropractor are not covered.
Therefore, we decided that the Plan does not have to pay for chiropractic therapy services provided on
December 26, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nurse (SN) visits to be provided in the home
health setting.
You asked the Plan to pre-approve the continued home health services. You say that the enrollee requires these
intermittent nursing visits to assist with maintenance of his medical condition. The Plan denied your request.
The Plan says that the enrollee has had this covered for years and the plan will not authorize any further visits.
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing
coverage of home care services.
There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services
at issue in this appeal. Therefore, we decided that the Plan has to pre-approve continued skilled nurse (SN)
visits to be provided in the home health setting.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - four radiographic
images (D0274) and comprehensive oral evaluation - new or established patient (D0150) provided on February
25, 2020 by a non-plan provider.
You asked the Plan to pay for the dental services. You say that you were not previously advised that you would
be required to use a participating provider. The Plan denied your request. The Plan says you do not have out-ofnetwork
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.
The provider is not in-network and your EOC clearly states, you must use a participating plan provider for
covered dental services. Therefore, we decided that the Plan does not have to pay for prophylaxis - adult
(D1110), bitewings - four radiographic images (D0274) and comprehensive oral evaluation - new or
established patient (D0150) provided on February 25, 2020 by a non-plan provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on December
5, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you were told this treatment
was 100% covered. You say it is out of your means to pay this bill. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of
the Medicare-allowed amount for in-network Medicare Part B covered drugs.
You have been asked to pay $162.36 which is 20% of the allowed amount for the Part B injection. The allowed
amount is $811.80. ($811.80 x 20% = $162.36). The Part B injection falls within the "Medicare Part B
prescription drugs" 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 Part B injection
provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397)
provided to the enrollee on November 25, 2019.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an
established relationship between the member and the ordering physician. The Plan states there were no claims
submitted for an evaluation and management service. The Plan states the review of claims history for this
member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or
Telehealth service with the ordering physician as required per CMS guidelines.
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 orthosis and sleeve. Our reviewer says
that the enrollee does not meet criteria for the orthosis and sleeve ordered. Our physician reviewer found the
documentation in the case file does not support that the requested knee orthosis and sleeve were medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and
there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not
separately payable when the base item is not covered.
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 orthosis and sleeve have not been met.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical
equipment is no less than five years. Replacement equipment may be granted when irreparable wear or
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same orthoses from a different provider on April 2, 2019. This orthosis is still within
the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn,
irreparably damaged, or that the enrollee had a change in medical condition to warrant the suspension sleeve at
issue. Based on this information, we decided that Medicare rules for coverage of the orthosis and sleeve have
not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and
suspension sleeve (L2397) provided to the enrollee on November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bacillus Calmette-Guerin for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Bacillus Calmette-Guerin with Interferon alfa-2b is not a mix of drugs that is supported in the NCCN guidelines for non-invasive bladder cancer.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review relates to a request for BCG to be given into the bladder with Interferon to treat cTa low grade recurrent bladder cancer in the enrollee. The use of this combination is not supported by FDA indication nor by any of the CMS approved compendia. The NCCN Guidelines Version 5.2020 Bladder Cancer do not include the use of Interferon in combination with BCG. Therefore, the documentation does not support that the requested use of BCG in combination with Interferon is medically reasonable and necessary nor that it is safe and effective for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Bacillus Calmette-Guerin for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on October 17, 2019.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.

The Plan must follow Medicare rules. The rules say that modifier 80, 81 or 82 must also be billed when modifier AS is billed.

We looked at the file and Medicare rules. The file shows that procedure code 49650 was not billed with required modifier 80, 81, or 82 to signify an assistant surgeon. 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 assistant surgeon services rendered on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the
enrollee on February 4, 2020.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported by the records.
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 orthosis have not been met. Documentation submitted did not
indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be
verified. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis
(L3960) provided to the enrollee on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar-sacral orthosis (L0650) provided to the enrollee
on September 25, 2019.
You asked the Plan to pre-approve the orthosis. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an
established relationship between the member and the ordering physician. The Plan states there were no claims
submitted for an evaluation and management service. The Plan states the review of claims history for this
member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or
Telehealth service with the ordering physician as required per CMS guidelines.
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 orthosis. Our reviewer says that the
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the available
documentation in the case file does not support that the requested lumbar-sacral orthosis was medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. An appropriate history and a physical examination of the back would reasonably be required to
adequately assess whether the coverage criteria for an LSO have been met. The documentation does not
support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as
there is no documentation of a credible physical examination of the back.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve lumbar-sacral orthosis (L0650) provided to the enrollee on September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to pre-approve SNF services. You say that the member has been improving and would like
to continue therapy to gain enough strength to go to an assisted living facility. The Plan denied your request.
The Plan says that the enrollee does not meet Medicare criteria for SNF coverage.
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 the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Periodontal Maintenance (D4910) provided February 25, 2020.
You asked the Plan to pay for the Periodontal Maintenance. You say that the service was covered in the past and should be covered. The Plan denied your request. The Plan says this service is not a covered benefit.
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 Periodontal Maintenance (D4910) provided February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral knee orthoses (L1851) and suspension sleeves (L2397) provided to the enrollee on October 10, 2019.You asked the Plan to pay forthe orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states therewere no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1851) and suspension sleeves (L2397) provided to the enrollee on October 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. Your functional level does not require skilled therapy services to safely and effectively provide medically necessary andreasonable treatment in a SNF. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.