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

We decided that the Plan does not have to pay for the services provided to you by an opt-out provider on August 21, 2019.You asked the Plan to pay for the services. You say that you were reimbursed previously for these services.The Plan denied your request. The Plan says this provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the physician. This provider has opted out of the Medicare program. The file shows that the requested provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the services provided to you by an opt-out provider on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214), an x-ray (73610), an injection beneath the skin or into muscle for therapy, diagnosis, or prevention (96372), and an injection of dexamethasone sodium phosphate (J1100) provided on September 3, 2019 by out of network provider.You asked the Plan to pay foran office visit, an x-ray and injections. You say that you are appealing the denied claim and say the notes will support the need for services.The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The plan did not authorize any services non-participating providers. The services are not considered urgent/emergent in nature. Services rendered by non-participating providers, require prior authorization as outlined in the enrollee's EOC. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services.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 nota network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit (99214), an x-ray (73610), an injection beneath the skin or into muscle for therapy, diagnosis, or prevention (96372), and an injection of dexamethasone sodium phosphate (J1100) provided on September 3, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2) and an extraction of an impacted tooth with some bone (D7230) for tooth # 32.You asked the Plan to pre-approve guided tissue regeneration and the extraction of tooth # 32. You say that the enrollee needs an extraction by an oral surgeon due to medical history.The Plan denied your request. The Plan says the services you received are not listed as covered services.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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2) and an extraction of an impacted tooth with some bone (D7230) for tooth # 32.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultraviolet light therapy system provided on August 22, 2019.You asked the Plan to pay forthe ultraviolet light therapy system (E0691). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the documentation did not include a valid physician order, Proof of Delivery,or Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order or aproof of delivery for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay forthe ultraviolet light therapy system provided on August 22, 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 by on July 1, 2019.You asked the Plan to pay for the orthoses. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior 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 non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided by on July 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthoses and suspension sleeves provided on August 19, 2019.You asked the Plan to pay forthe knee orthoses (L1851)and suspension sleeves (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.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. The enrollee address you submitted on medical records, written order,and proof of delivery documentation does not exist. 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 forthe knee orthoses and suspension sleeves provided on August 19, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the claim should be paid. The
Plan denied your request. The Plan says the documentation does not indicate services are necessary for
treatment of the enrollee's condition.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device
(E0652)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml Soln Pref Syr.You asked the Plan to pre-approveProlia 60mg/ml Soln Pref Syr. You say that the requested medication is necessary.The Plan denied your request. The Plan says medical necessity has not been established.Therefore, coverage criteria has not been 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 Prolia 60mg/ml Soln Pref Syr. Our reviewer says that the item is not medically necessary. Our physician reviewerfound the submitted medical records do not support that Prolia is medically reasonable and necessary or 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 Prolia 60mg/ml Soln Pref Syr have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia 60mg/ml Soln Pref Syr.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960) and suspension sleeve (L2397) provided by on August 23, 2019.You asked the Plan to pay for the orthoses. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, no claims were submitted for an evaluation and management service and there is no evidence of a prior 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 non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) 
shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960) and suspension sleeve (L2397) provided by on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three autogenous connective tissue graft procedures.You asked the Plan to pre-approvethe autogenous connective tissue graft procedures. The Plan denied your request. The Plan says this service is not covered under your benefit 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 decided that the Plan does not have to pre-approvethree autogenous connective tissue graft procedures.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99334) provided on March 29, 2019 by out of network provider.You asked the Plan to pay fora domiciliary or rest home visit. You say that your provider, cannot deny any medical services that are essential for patient health treatment. You are requesting to have the charges reviewed and be retro-authorized.The Plan denied your request. The Plan says the non-urgent services are not authorized because the physician is a non-network provider with the member's health plan, and member self-directed. The member's network primary care physician (PCP) did not refer for services. The health 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora domiciliary or rest home visit (99334) provided on March 29, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an over the counter (OTC)item, Mederma Advanced Scar Topical, provided on November 6, 2019.You asked the Plan to reimburse you for the OTC item. The Plan denied your request. The Plan says the contents are a cream with no active ingredients, which is consider cosmetic in nature, and therefore, is not covered by Medicare under the OTC benefit. Only medicated lotions or creams with 4% lidocaine are covered under the OTC benefit.The Plan must follow Medicare rules. The rules say that Medicare does not payfor OTC items and Mederma Advanced Scar Topical is an OTC item. Therefore,we decided that the Plan does not have to reimburse you for over the counter (OTC), Mederma Advanced Scar Topical, providedon November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on August 14, 2019.You asked the Plan to pay for the eye exam. You say that you have not seen this provider in several years and this is the only eye exam you have had in the 2019 calendar year. The Plan denied your request. The Plan says you have exceeded the calendar year maximum for this benefit.Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that on April 29, 2019,you had an eye exam rendered by you physician. Per your 2019 Evidence of Coverage, you are allowed one routine eye exam each calendar year. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on August 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erlotinib tablets 25 MG.You asked the Plan to pre-approveErlotinib tablets. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Erlotinibtablets are not covered by the enrollee's Medicare Part B 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-approveErlotinib tablets 25 MG.Benefits for Erlotinib tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September
13, 2019.
You asked the Plan to pay for the physician services. You say that the enrollee received medical services by a
provider within the group. You say that the services that the enrollee received should be covered and paid in
network. You also say that the services were medically necessary. The Plan denied your request. The Plan says
the enrollee was enrolled in hospice at the time you provided the services. The Plan says the Medicare hospice
benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date
of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers
attending physician services and all care unrelated to the terminal illness until the first day of the month
following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on September
13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for A Diagnostic Digital Breast Tomosynthesis (77061) provided October 1, 2019.  You asked the Plan to pay for the Digital Breast Tomosynthesis. You say that the service was medically necessary. The Plan denied your request. The Plan says the code billed is not valid for Medicare payment.
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 77061 is not supported in the medical record. Specifically, per the 2019 National Physician Fee Schedule, procedure code 77061 has a status code of "I" which is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the Digital Breast Tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for A Diagnostic Digital Breast Tomosynthesis (77061) provided October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 21, 2019 by out of network provider.You asked the Plan to pay for an office visit. You say that the member has been coming to you since 2017. You say that prior authorization was never required before.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that both providers are also out-of-network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for an office visit provided on March 21, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549, 99082.
You asked the Plan to pre-approve the compression stockings. You say that the stockings should be covered because these compression stockings will prevent blood clots with immobility after my knee surgery. The Plan denied your request. The Plan says these stockings are examples of wound care items which are non-covered under surgical dressing benefit because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549, 99082 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549, 99082.