Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) provided on March 3, 2020 and March 5, 2020.
You asked the Plan to pay for the physical therapy. You say that the physical therapy provided on March 3, 2020 and March 5, 2020 was medically necessary. The Plan denied your request. The Plan says the physical therapy provided on March 3, 2020 and March 5, 2020 was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee had PT visits from December 4, 2019 to March 5, 2020 for a history of falls, functional decline, difficulty walking, low back pain with recent 2-month exacerbation. Physical therapy has been utilized. The member has mobility and mobility related activities of daily living deficits. She has back pain, improved with therapy. Her balance is impaired, and her core strength is weak. She lives in a multi-level residence with 14 steps to enter.
For back pain, physical therapy (PT) is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication residual deficits could not be addressed via a home exercise program. Therefore, the PT services provided in this case are deemed 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 the physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) provided on March 3, 2020 and March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 17, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says there is no valid referral for 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 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 psychotherapy services provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on . to January 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the nursing home is responsible to obtain prior authorization. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
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 on . to January 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided from December 24, 2019 to December 25, 2019.
You asked the Plan to pay for home infusion therapy. You say that these services should be covered. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 S9500 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided from December 24, 2019 to December 25, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a lateral femoral cutaneous nerve block.
You asked the Plan to pre-approve the lateral femoral cutaneous nerve block. You say that the enrollee is in a lot of pain. The Plan denied your request. The Plan says that the requested procedure is considered investigational and is not eligible for coverage of the treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases. The plan says that the requested injection services are experimental.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the lateral femoral cutaneous nerve block. Our reviewer says that the injection services being requested are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is obese and has diabetes. He is taking Lyrica, Tizanidine and Lidocaine transdermal for his pain. He has tried conservative treatments including massage, Physical therapy, acupuncture and yoga. He describes a painful area about his hip and thigh. The differential diagnosis includes Meraglia parathestica. This is not diabetic neuropathy, rather it is an entrapment syndrome. The requested procedure is the standard of care and is medically reasonable and 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 the lateral femoral cutaneous nerve block have been met. Therefore, we decided that the Plan has to pre-approve a lateral femoral cutaneous nerve block.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a VirtuClean Sleep Cleaning Machine 2.0.
You asked the Plan to pre-approve a CPAP cleaner and sanitizer device. You say that you are not able to dismantle the CPAP machine to wash and sanitize each piece. The Plan denied your request. The Plan says this device is for cleaning the machine and is not necessary for treatment of an illness or injury, or to improve the functioning of a malformed body member.
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. The owner of the
machine is expected to do routine maintenance. Therefore, we decided that the Plan does not have to pre-approve a VirtuClean Sleep Cleaning Machine 2.0.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
You asked the Plan to pre-approve hearing aids. The Plan denied your request. The Plan says that hearing aids
outside of approved brand or not TruHearing branded item are not a covered benefit by the plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only from a TruHearing provider.
We looked at the file and the Plan's rules. The file indicates you have not requested the hearing aids from a
TruHearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids
have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids from an outof-
network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 19, 2019.
You asked the Plan to pay for the laboratory services. 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 laboratory services provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 16, 2019.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physician's
custom profile. The Plan denied your request. The Plan says the documentation did not contain evidence of a
relationship with the ordering physician.
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 presumptive and definitive drug testing services are not supported in medical records. Based
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that
the Plan does not have to pay for the drug testing services provided on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement knee orthosis.
You asked the Plan to pre-approve a replacement knee orthosis (A4467). You say that you need a replacement
brace like the one you have so you can walk. The Plan denied your request. The Plan says this brace is not rigid
or semi-rigid device and therefore not covered.
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. This brace is statutorily not covered by Medicare. Based on this
information, we decided that Medicare rules for coverage of a replacement knee orthosis (A4467) have not
been met. Therefore, we decided that the Plan does not have to pre-approve a replacement knee orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need the requested orthotics because of your medical conditions. You say that the shoes you currently have are no longer in good condition. You asked the Plan to review the authorization request. 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 orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided on April 12, 2019.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says that this service is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided at a network optical provider. We looked at the file and the Plan's rules. You did not receive the eyewear from a network optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on April 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on December 27,
2019.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit
and you disagree with the charges. The Plan denied your request. The Plan says 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0
copayment for an annual physical provided by a primary care physician. If, during the physical exam, you also
receive services to treat a medical condition, you will be expected to pay a $10 copayment for the additional,
Medicare-covered services.
The claim was submitted with multiple diagnostic codes for an office visit provided on December 27, 2019.
Therefore, services beyond an annual wellness visit took place. Therefore, you are responsible to pay the $10
copayment.
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the
physician/practitioner services, including doctor's office visits 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 an office visit provided on December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.
You asked the Plan to pre-approve Freestyle Lite test strips. You say that these strips are available at the non-profit clinic where the member fills his prescriptions. The Plan denied your request. The Plan says that you have told them the enrollee can use one of their preferred systems.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue are Freestyle Lite test strips. Freestyle is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary.The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records, the acute care hospital is able to provide all of the services the enrollee requires. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on August 21, 2019 by an OON provider.You asked the Plan to pay for the endodontic therapy. You say that your primary dentist referred you to this treating provider for a root canal. You also say that it was necessary for you to go out-of-network to get your treatment.The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that endodontic therapy (D3330) 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 covered when they are received OON. The 2019 Dental Benefits Schedule also does not list endodontic therapy (D3330) as a covered benefit.Therefore, we decided that the Plan does not have to pay for the endodontic therapy provided on August 21, 2019 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-rays provided from November 25, 2019 and December 4, 2019.You asked the Plan to waive the copayments for X-rays. You say that you disagree with the charges because the X-rays were not performed correctly.The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each X-ray.You received X-rays on November 25, 2019 and December 4, 2019. Therefore, you are responsible to pay the allowed amount of $72.96 per each X-ray. The total amount you owe is: $145.92, which is less than the total copayment amount.  You have been asked to pay the total copayment amount of $145.92 for X-rays. X-rays fall 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 for X-rays provided from November 25, 2019 and December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a radial styloidectomy (25230) provided on November 21, 2019.You asked the Plan to pay for surgical assistant services. You say that the surgical assistant had no choice and should be paid.The Plan denied your request. The Plan says surgical assistant services are not covered for this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 25230. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met.Therefore, we decided that the Plan does not have to pay for surgical assistant services on a radial styloidectomy (25230) provided on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora CPAP device (E0601) provided on November 26, 2019.You asked the Plan to pay for the CPAP device. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code E0601 was not billed with the required durable medical equipment modifier.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 E0601 is not supported in the record. Specifically, the CPAP device is a capped rental item meaning it cannot be provided for purchase using modifier -NU. It must be billed with the -RR modifiers for the total rental period until the maximum amount of rental payments are made.  Based on this information, we decided that Medicare rules for coverage of the CPAP device have not been met.Therefore, we decided that the Plan does not have to pay fora CPAP device (E0601) provided on November 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance transports (A0428) provided November 5, 2019 to December 10, 2019.You asked the Plan to waive the copayments for the ambulance transports. You say that the copayments should be waived because you were sent back and forth to the hospital due to errors made by the hospital.The Plan denied your request. The Plan says the correct copayments were applied.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 $225 copayment for Ambulance Services. You have been asked to pay a $225 copayment for the ambulance transports. The ambulance transports fall 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 copayments for ambulance transports (A0428) provided November 5, 2019 to December 10, 2019.