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

We decided that the Plan does not have to pay for trigger point injections provided on September 23, 2019.
You asked the Plan to pay for the trigger point injections. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 trigger point injections provided on September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts.
You asked the Plan to pre-approve foot inserts. You say that a foot orthotic is needed to relieve pressure and imbalance. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to waive the copayment forthe urgent care visit provided on October 20, 2019.You asked the Plan to waive the copayment forthe urgent care visit. You say that you were told the provider was in-network and you did not see a doctor. You say you saw a nurse and were charged a $40 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 urgent care visit within the United States. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 forthe urgent care visit provided on October 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power wheelchair power seat elevation feature (E2300). You say that the seat elevation feature is a medical necessity for your mental stability and to stay as active as possible. The Plan denied your request. The Plan says power seat elevation features do not serve a primarily medical purpose and are statutorily not covered by Medicare or the Plan.
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. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on August 5, 2019.You asked the Plan to pay forthe orthoses 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 claimssubmitted 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 forknee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on August 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 29, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a chemotherapy injection (J0897 and 96401) provided on May 9, 2019.
You asked the Plan to waive the coinsurance for a chemotherapy injection. You say that this should be covered. The Plan denied your request. The Plan says this claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B covered Drugs and chemotherapy drugs. You have been asked to pay a $235.03 coinsurance for a chemotherapy injection ($1175.17 allowed amount x 20% = $253.03). A chemotherapy injection falls within the Medicare Part B covered Drugs and chemotherapy 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 a chemotherapy injection (J0897 and 96401) provided on May 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 3, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 laboratory services provided on September 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (Nivolumab) in combination with Gemcitabine for the enrollee.
You asked the Plan to pre-approve Opdivo. The Plan denied your request. The Plan says there is no literature for the requested drug in combination with Gemcitabine for advanced stage non-small cell lung cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. The file shows that chemotherapy with Gemcitabine and Nivolumab were requested for the enrollee. The plan has agreed to pre-approve Gemcitabine. 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 Opdivo. Our physician reviewer found that the enrollee has metastatic non-small cell lung cancer. The requested use of Nivolumab is not FDA-approved in combination with Gemcitabine for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use listed as not indicated, not supported or not recommended in any of the compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (Nivolumab) in combination with Gemcitabine for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI provided on June 12, 2019.You asked the Plan to waive the copayment forthe MRI. You sent in your bill for review. You say the service was not performed correctly. 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 $75 copayment for each visit for the following Medicare-covered diagnostic radiology procedures: computed tomography (CT), magnetic resonance (MRIs and MRAs), and nuclear medicine studies, which includes PET scans. You have been asked to pay a $75 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you received an MRI on June 12, 2019.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 forthe MRI provided on June 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lumbar spine. Our reviewer says that the requested MRI is not medically necessary at this time. Our physician reviewer found the documentation shows that you report left sided back pain with pain radiating to your feet and increased with walking. A physical examination notes negative bilateral straight leg raises, sensory changes in bilateral L5 distribution and bilateral lumbar paraspinal muscle tenderness. Reviewed documentation does not outline conservative measures, plain film imaging, or differential diagnosis. Without with this information, medical necessity cannot be determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection and epidural injection provided on July 26, 2019 and October 30, 2019.
You asked the Plan to waive the copayment for the facet joint injection and epidural injection. You say that you had other injections that you were not charged for. You say that you did not know the price and do not want to pay. The Plan denied your request. The Plan says the copayments 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 $350 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a total of $700 for the facet joint injection and epidural injection. ($350/injection x 2 injections = $700). The facet joint injection and epidural injection fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The injections are considered 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 facet joint injection and epidural injection provided on July 26, 2019 and October 30, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the lumbar spine for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a second compression fracture on November 10, 2019 in the setting of a prior compression fracture and known spinal stenosis. Her acute symptoms from the new fracture have improved but chronic symptoms persist. The neurosurgeon documented a plan to reevaluate with advanced imaging in six weeks on December 11, 2019 to assure healing for a considered laminectomy. The procedure being considered is documented in the records. The CT scan is reasonable and medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the lumbar spine for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl for the enrollee.
You asked the Plan to pre-approve Fentanyl. You say that the enrollee has had excellent results on Fentanyl. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Fentanyl for the enrollee.
Benefits for Fentanyl 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional dental extractions.You asked the Plan to pre-approveadditional dental extractions. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you have been approved for two dental extractions for the calendar year. The Plan states the remaining extractions will not be covered.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 at this time. Your contract with the Plan clearly states youare limited to two dental extractions per calendar year. The file shows that the Plan approved two dental extractions, which is the allowed amount for the calendar year for this service.Therefore, we decided that the Plan does not have to pre-approveadditional dental extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for back-up battery for CPAP machine purchased May 10, 2019.
You asked the Plan to pay for the back-up battery. You say that you were told by a plan representative that the battery would be covered. You do not have the extra money but you need the battery because you lost power twice in the middle of the night. 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 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 pay for back-up battery for CPAP machine purchased May 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you require this to see a specialist you were referred to. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services provided to the enrollee on August 9, 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 this is a duplicate of a charge considered on a previous claim.
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 99284 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found there is evidence that CPT 99284 has been charged twice for 8/9/2019. The provided records seem to indicate that the enrollee had three separate ED visits on 8/9, 8/10 and 8/23. Furthermore, the 8/9 note seems to indicate that the enrollee may have had a fourth ED visit on 8/8. Unfortunately, the provided records are blurry, dark and difficult to read. They are also incomplete, providing insufficient documentation as to the enrollee's arrival times, departure times and dispositions (ex. home, observation). It is unable to be determined if separate ED evaluations occurred, on what days, and how they should be billed. It is highly unusual for two ED claims to be submitted on the same day using the 25 modifier. Such billing would indicate that the enrollee was seen for one problem and after discharge suffered a new problem promptly return to the ED for evaluation of the new problem. Two evaluations on the same day for the same problem are usually bundled as one charge. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department services provided to the enrollee on August 9, 2019.