Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental anesthesia (D9215) provided January 30, 2020.You asked the Plan to pay for the dental anesthesia. You say that the anesthesia should be covered.The Plan denied your request. The Plan says the 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 dental anesthesia (D9215) provided January 30, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an outpatient visit (99214) provided on November 14, 2019.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration because these services were billed correctly. The Plan denied your request. The Plan says that Original Medicare does not allow all professionals such as registered nurses, nurse practitioners, clinical nurse specialists or certified registered nurse anesthetists to directly submit charger for the services that they provide.
The Plan must follow Medicare rules. Medicare rules say that in general, NPs (Nurse Practitioners) are paid for covered services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit (99214) have been met. Specifically, the provider in this case is a NP, for which Medicare states payment can be made. The NP has their own NPI on the claim form (in addition to the Billing Provider's NPI). The Plan states that the rendering provider taxonomy submitted on the claim was that of a Registered Nurse (RN). The claim form within the record does not show that a taxonomy of RN was submitted, and the Plan denial rationale is not substantiated. Therefore, we decided that the Plan has to pay for an outpatient visit (99214) provided on November 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz knee injections.
You asked the Plan to pre-approve the Supartz injections. You say that you should be allowed to try these injections before being referred for knee surgery which you are hoping to avoid. The Plan denied your request. The Plan says the criteria for coverage of this injection are not met.
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 Supartz injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary for this enrollee's condition. Our physician reviewer found the enrollee is a female with multiple medical problems, morbid obesity, and bilateral knee pain due to bilateral medial meniscus tear. Treatment to date has included medication, activity modification, and corticosteroid injections. Diagnostic studies to date have included x-rays. Hyaluronic acids (such as Supartz) are naturally occurring substances in the body's connective tissues that cushion and lubricate the joints. Intra-articular injection of hyaluronic acid can decrease symptoms of osteoarthritis of the knee. Intra-articular injections with hyaluronic acid are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments. While osteoarthritis of the knee can be a recommended indication, there is insufficient evidence for other conditions. The review has determined that the enrollee does not meet criteria for the requested intra-articular injection of the right knee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Supartz injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz knee injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for personal care services (T1019) provided on September 28, 2019 through October 4, 2019.You asked the Plan to pay for the personal care services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the member's Long Term Care line of business terminated prior to the date of service.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 T1019 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code T1019 has a status code of I. This means that CPT code T1019 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met.Therefore, we decided that the Plan does not have to pay for personal care services (T1019) provided on September 28, 2019 through October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on November 22, 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 services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on November 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from December 28, 2019 to December 31, 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 a FIPS code is required to identify the county where the services are rendered.
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 the denied codes are not supported in the medical record. Specifically, the claim cannot be processed for payment until a corrected claim has been received. There is no Federal Information Processing Standards (FIPS) code was not submitted. 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 home health services provided to the enrollee from December 28, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.You asked the Plan to pre-approve the genicular nerve block. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says this nerve block has not been proven effective for the treatment of knee pain.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 genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is experimental/investigational and the subject of on-going trials.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 genicular nerve block have not been met.Therefore,we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a L300 Go Lower System and L300 Go Thigh Plus System (FES devices).
You asked the Plan to pre-approve a L300 Go Lower System and L300 Go Thigh Plus System. You say that this is a recommended clinical practice. The Plan denied your request. The Plan says this has not been shown to be effective for your condition.
The Plan follows Medicare rules. Medicare rules say that NMES is covered for disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy or a spinal cord injury. 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 L300 Go Lower System and L300 Go Thigh Plus System. Our reviewer says that the coverage criteria for these devices have not been met. Our physician reviewer found the records do not indicate you have disuse atrophy or a spinal cord injury. The records do not support that you could not respond to standard therapy, strengthening, and electrical therapy. As such, a FES device is not medically 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 a L300 Go Lower System and L300 Go Thigh Plus System have not been met. Therefore, we decided that the Plan does not have to pre-approve a L300 Go Lower System and L300 Go Thigh Plus System (FES devices).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on February 20, 2020.You asked the Plan to pay for the self-administered drugs. You say that you would like reconsideration because you were not aware that these drugs were not covered.The Plan denied your request. The Plan says Part B generally doesn't pay for self-administered drugs used in the hospital outpatient setting.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 pay for self-administered drugs provided on February 20, 2020.Benefits for the self-administered drugsmay 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hormone implantation (11980) provided on January 15, 2019 through September 10, 2019.
You asked the Plan to pay for the hormone implantation. You say that you would like reconsideration because the hormone implantation is medically necessary. The Plan denied your request. The Plan says these services are not covered when associated with menopause.
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 hormone implantation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested items. 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 hormone implantation have not been met. Therefore, we decided that the Plan does not have to pay for hormone implantation (11980) provided on January 15, 2019 through September 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for Skilled Nursing Facility services provided on October 1, 2019 through October 18, 2019.You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that payment is not allowed for this service because the PDPM code submitted is inconsistent with what was approved on the authorization.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to identify a substantive reason as to why the actual PDPM billed was incorrect based on the member's condition. Additionally, the Type of Bill code submitted is valid for the services billed.Therefore,we decided that the Plan has to pay for Skilled Nursing Facility services provided on October 1, 2019 through October 18, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility services provided on November 16, 2019 through December 15, 2019.
You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member's condition no longer required daily skilled services at an inpatient skilled nursing facility level.
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 pay for the Skilled Nursing Facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member did not meet severity of illness or intensity of service criteria for 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 the Skilled Nursing Facility services have not been met. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility services provided on November 16, 2019 through December 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist/hand orthosis (L3916) provided January 8, 2020.
You asked the Plan to pay for the orthosis. You say that the submitted records should support the necessity of the services in dispute. 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 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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the submitted records are unrelated to the provided services. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 pay for wrist/hand orthosis (L3916) provided January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Privigen injection.You asked the Plan to pre-approve the repeat injection. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says Medicare requires periodic testing and reevaluation of immune-globulin (IgG) level(s) to determine dose and frequency of treatments for covered diagnoses as listed in the Medicare Local Coverage Determination.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 repeat injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found recent monitoring of IgG levels and current clinical status was not provided via documentation to help support additional IVIG treatment at this time. The most recent progress note provided is from 10/10/2019.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 repeat injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a repeat Privigen injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you have been living with Multiple Sclerosis since April of 1989. You are unable to walk and have to use a wheelchair to getaround. You say that you are being treated for wounds caused by your urinary incontinence and you need to use the requested supplies.The Plan denied your request. The Plan says this item is not a covered benefit.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 pre-approveincontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on December 16, 2019.You asked the Plan to waive the copayment for ambulance transport. You say that you are appealing.The Plan denied your request. The Plan says the copayment amount you are being charged 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 $200 copayment for ambulance transport. You have been asked to pay $200 copayment for ambulance transport. ambulance transport falls within the Ambulance 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 ambulance transportation provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for3 units of CPT 64450 provided on August 28, 2019.You asked the Plan to pay for3 units of CPT 64450. The Plan denied your request. The Plan says only one unit of this service is allowed.The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.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 3 units of CPT 64450 Our reviewer says that 3 units of CPT 64450 is not supported by the records provided. Our physician reviewer found that the enrollee received a nerve block to his knee. Three branches of the genicular nerve were injected. An injection code is assigned to each nerve that is injected, not to each injection or to each branch that is injected. As only one nerve was injected (the genicular nerve) coding of only one nerve block is supported.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 units of CPT 64450 have not been met.Therefore, we decided that the Plan does not have to pay for3 units of CPT 64450 provided on August 28, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 10, 2019.You asked the Plan to waive the copayment for the ambulance transport. You submitted your bill for review.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 $200 copayment per date of service regardless of the number of trips for ground ambulance.You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on December 10, 2019.
Appeal type: Practitioner Services
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 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 12, 2019.