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

We decided that the Plan does not have to pre-approveenteral formula, nutritionally complete, for special metabolic needs (Glucerna) (B4154).You asked the Plan to pre-approvethe enteral formula. You say that this needs to be covered due to having anemia, osteoporosis, osteoarthritis and high cholesterol.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approveenteral formula, nutritionally complete, for special metabolic needs (Glucerna) (B4154).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-therapeutic Medtronic Guardian Sensor 3 sensors.You asked the Plan to pre-approvenon-therapeutic Guardian Sensor 3 sensors. You say that youhave seen improvements in your eye complications and glucose level control with the Guardian Sensor 3.The Plan denied your request. The Plan says the Guardian Sensor 3 is classified as non-therapeutic by Medicare and is excluded from coverage.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor supplies havenot been met.Therefore, we decided that the Plan does not have to pre-approvenon-therapeuticMedtronic Guardian Sensor 3 sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel seat cushion with breathable fabric (A9270).
You asked the Plan to pre-approve the seat cushion. You say that the enrollee is completely disabled and sits for a long period of time. You've had to go to the dermatologist service times because he developed ulcers from sitting. The Plan denied your request. The Plan says this item is a convenience item not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve Gel seat cushion with breathable fabric (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveindwelling latex catheters (A4338) of 348 per month.You asked the Plan to pre-approvethe catheters. You say that it is medically necessary for the enrollee to place a new catheter each night.The Plan denied your request. The Plan says the additional 348 catheters exceeds the Medicare allowable of 1 per month. The plan also says that if you are in need of catheters to insert into your bladder and help drain urine as needed, this has to be requested using a different code.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. Based on this information, we decided that Medicare rules for coverage of the catheters have not been met.Therefore, we decided that the Plan does not have to pre-approveindwelling latex catheters (A4338) of 348 per month.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe neuromuscular junction (NMJ) testing provided during intraoperative neuromonitoring on June 11, 2019 billed with code 95937.You asked the Plan to pay forthe NMJ testing. You say that this is correctly billed.The Plan denied your request. The Plan says this code is not correct to report train of four testing.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 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the medical record. Specifically, this is being billed to report train-of-four testing. This is not a valid code for this service. Based on this information, we decided thatMedicare rules for coverage of the NMJ testing have not been met.Therefore, we decided that the Plan does not have to pay forthe neuromuscular junction (NMJ) testing provided during intraoperative neuromonitoring on June 11, 2019 billed with code 95937.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve6 visits with a neurologist to be provided by out of network provider, "the doctor".You asked the Plan to pre-approveoffice visits. You say that you requested an appeal to reconsider the denial of out-of-network neurologist referral to "the doctor". You also say that the provider referred you to a neurologist to treat autonomic dysfunction. You further say that the provider looked and was unable to find a neurologist in a three-county area that treats this condition.The Plan denied your request. The Plan says there are at least sixin-network providers available to you that are available to provide this service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve6 visits with a neurologist to be provided by out of network provider, "the doctor".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelower extremity orthosis, elastic knee sleeves for both knees (L2999x2).You asked the Plan to pre-approvethe elastic knee sleeves. You say that the records provided will show proof of medical necessity.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that elastic or fabric support garments are non-coveredbecause they are not rigid or semi-rigid devices. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the elastic knee sleeves have not been met.Therefore, we decided that the Plan does not have to pre-approvelower extremity orthosis, elastic knee sleeves for both knees (L2999x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pay forthe assembly and operation of a heart-lung machine provided by a perfusionist on August 16, 2019 during an inpatient admission.You asked the Planto pay forthe heart-lung machine services. You say that this code is for the operation of the heart-lung machine. This takes about 30-60 minutes to assemble and the perfusionist is required to be there for the entire procedure. This must be paid as medically necessary.The Plandenied your request. The Plansayspayment for this service is included in payment to the facility.The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.Although these services may be appropriate, payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue.Therefore, we decided that the Plandoes not haveto pay forthe assembly and operation of a heart-lung machine provided by a perfusionist on August 16, 2019 during an inpatient admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe low air loss mattress to be provided You asked the Plan to pre-approvethe mattress. You say that you had a stage 4 ulcer that is now in remission. Your current mattress has minor holes and the comfort level of your current mattress is horrible and making it very difficult for you.The Plan denied your request. The Plan says there are no currentulcers or pressure sores. The low flow air mattress is not covered by Medicare for prevention of skin breakdown.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. Based on this information, we decided that Medicare rules for coverage of the mattress have not been met.Therefore, we decided that the Plan does not have to pre-approvethe low air loss mattress to be provided.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the additional coinsurance for DME provided on May 28, 2019.You asked the Plan to waive the additional coinsurance for DME. You say that you already paid the $1,095.48 coinsurance and disagree with the additional charges of $193.32.The Plandenied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay 20% coinsurance for DME and related supplies. You received DME on May 28, 2019. The total allowed amount is $5,477.41 and 20% of that is $1,095.48. The Plan says you must pay $1,288.80 coinsurance for DME. Based on thePlan contract, however, you cannot be asked to pay more than 20% coinsurance for DME.Therefore, we decided that the Plan has to waive the additional coinsurance amount of $193.32 for DME provided on May 28, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran electrocardiogram (93010) provided on July 25, 2019.You asked the Plan to pay foran electrocardiogram. You say that this should be reprocessed for payment.The Plan denied your request. The Plan says the interpretation and report are not authenticated by the rendering physician.The Plan must follow Medicare rules. Medicare rules say that services must be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare's policies.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electrocardiogram have not been met. Specifically, the rendering provider of the electrocardiogram "the doctor" is thesame as the attending/ordering physician. This means that the "the doctor" is the person responsible for the care of the beneficiary. The record does not show that "the doctor" authenticated the medical records.Therefore, we decided that the Plan does not have to pay foran electrocardiogram (93010) provided on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on September 12, 2019.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that the Plan should pay for this service because the dentist was in-network with your plan.The Plan denied your request. The Plan says this service is not covered 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.Therefore, we decidedthat the Plan does not have to pay forthe problem focused limited oral evaluation provided on September 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on July 3, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on July 3, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the additional charges (beyond the $35 copayment) forthe steroid knee injection with image-guidance provided on April 4, 2019.You asked the Plan to waive the additional charges (beyond the $35 copayment) forthe steroid knee injection. You say that you feel that you should only have to pay for the $35 copayment as that is what you have paid in the past.The Plan denied your request. The Plan says that you were charged the $35 copayment for the visit. You were charged the allowed amount for the imaging-guidance which is less than the $100 copayment for diagnostic imaging. You were then charged 20% coinsurance for the Part B drugs that were injected.The Plan must follow Medicare rules. Medicare rules say that cost sharing must be clearly and accurately described in the contract. The contract says that enrollees must pay a $35 copayment for surgical services provided in a specialist's office.In this case, all codes billed by the provider are integral to the overall surgical services which is the steroid injection. Requiring separate cost sharing to be applied to the imaging, without which the surgery could not be performed is not appropriate and is not clearly described in the contract. You received a surgical service in the office setting which you would not have reasonably expected to cost more than the $35 copayment described in the contract.Therefore, we decided that the Plan has to waive the additional charges (beyond the $35 copayment) forthe steroid knee injection with image-guidance provided on April 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift recliner.You asked the Plan to pre-approve the seat lift mechanism of a seat lift recliner.You say that your seat lift recliner is not functioning and you need a new one.The Plan denied your request. The Plan says the assessment shows you are able to stand up from a chair with no assistance.The Plan must follow Medicare rules. Medicare does not cover the upholstered portion of a seat lift recliner.The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift reclinerhave not been met.Therefore, we decided that the Plan does not have to pre-approvethe seat lift mechanism of a seat lift recliner
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4K score testing.You asked the Plan to pre-approve4K score testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that 4K score testing is non-covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4K score testing have not been met.Therefore, we decided that the Plan does not have to pre-approve4K score testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive drug testing rendered to "the beneficiary" by "the provider" on July 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code G0483 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 G0483 is definitive drug testing, 22 or more drug classes.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation shows that only 15 drug classes were tested. 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 forthe definitive drug testing rendered to "the beneficiary" by "the provider" on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of the oxygenconcentrator and tanks.You asked the Plan to pre-approve continued use of the oxygen concentrator and tanks. You say that the enrollee needs the oxygen service.The Plan denied your request. The Plan says you need to submit additional information for the oxygen to continue to be approved for a longer period of time.
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. We looked at the file and Medicare rules. Documentation was requested by the Plan but not received. The recertification documentation was not submitted. Based on this information, we decided that Medicare rules for coverage of continued use of the oxygen concentrator and tanks have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of the oxygen concentrator and tanks
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30mg Otezla Tablets.You asked the Plan to pre-approve the Otezla. You say that this drug is indicated to treat the member's condition. The Plan denied your request. The Plan saysthis drug is not covered under the member's 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-approve 30mg Otezla Tablets. Benefits for the Otezla may be available under Medicare Part D.Contactthe 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 forthe laboratory work provided from January 9, 2019 to July 17, 2019.You asked the Plan to waive the copayments forthe laboratory work. You say that you were not aware that hospital labs have a $40 copayment, because in previous years there has not been a copayment.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 $40 copayment per day for lab services at an in-network outpatient hospital. You have been asked to pay a total of $87.36 for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe laboratory work provided from January 9, 2019 to July 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Fosfomycin Tromethamine antibiotic provided by the "medical center" on August 14, 2019.You asked the Plan to pay forthis medication. You say that "the plan" should cover the costof the antibiotic as it was provided to you in the emergency room.The Plan denied your request. The Plan says this self-administered drugprovided in an outpatient setting isnot a coveredbenefit under your policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug provided here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe Fosfomycin Tromethamine antibiotic provided by the "medical center". on August 14, 2019.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 25, 2018 through June 26, 2018.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient hospital care. Our physician reviewer found the review indicates that as of 11:52 a.m. on June 25, 2018 the enrollee was hemodynamically stable and appropriate for ambulance transportation with monitoring to a Plan facility for observation/admission level of care services. There was no documentation provided necessitating post-stabilization care services at the non-participating Plan facility as of 11:52 a.m. on June 25, 2018. Post-stabilization care services at the non-participating Plan facility were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 25, 2018 through June 26, 2018.