Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance forthe automatic external defibrillator provided on November 4, 2019.You asked the Plan to waive the coinsurance forthe automatic external defibrillator. You say that you shouldn't have to pay for something you never used.The Plan denied your request. The Plan says that you are liable for your cost sharing.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 Durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the automatic external defibrillator. The automatic external defibrillator falls within the Durable medical equipment (DME) and related 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 coinsurance forthe automatic external defibrillator provided on November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs rendered to you on October 10, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the coinsurance is too much compared to a previous claim. The Plan denied your request. The Plan says the coinsurance was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each in-network Medicare covered Part B drug.
Review of the file shows that you received Part B drugs on October 10, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the in-network Medicare covered Part B drug 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 the Part B drugs rendered to you on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Inogen One G4 portable oxygen concentrator and an Inogen lithium ion battery purchased on October 23, 2019.
You asked the Plan to pay for the Inogen One G4 portable oxygen concentrator and an Inogen lithium ion battery. You say that The Plan denied your request. The Plan says that your request is not a covered benefit because you purchased these devices and Medicare provides a coverage benefit only for rental of these devices.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for the Inogen One G4 portable oxygen concentrator and an Inogen lithium ion battery purchased on October 23, 2019.
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 have a deformed right foot and have been getting prescribed shoes and inserts for the past several years. You say that your records show that the requested orthotics are medically necessary for you. You stated that you do not understand the Plan's denial of the requested orthotics. You say that with the orthotics you have been able to walk without much pain.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 maybe 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) services provided from October 1, 2019 to October 27, 2019.You asked the Plan to waive the copayment forthe SNF services. The Plan denied your request. The Plan says that the 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 $128 copayment per day, for days 21 to 100 of SNF care. You have been asked to pay a $896 copayment for the SNF services. The SNF services falls within the days 21 to 100 of SNF care 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 skilled nursing facility (SNF) services provided from October 1, 2019 to October 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean apicoectomy (D3410) and a retrograde filling (D3430) for tooth # 11.You asked the Plan to pre-approvethe dental services. You say that tooth # 11 has been causing you pain since you received a root canal in early July 2019. You say that in February 2020 you were put on antibiotics for an infection and are still experiencing persistent tooth pain.The Plan denied your request. The Plan says an apicoectomy and retrograde filling 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 requested dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean apicoectomy (D3410) and a retrograde filling (D3430) for tooth # 11.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on July 24, 2019.You asked the Plan to pay fortrain of four testing. You say that this was a medically necessary service.The Plan denied your request. The Plan says payment of this service is bundled into other services.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 95999 is not supported in the medical record. Specifically, theuse of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based onthis information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 the office visit provided on November 12, 2019 by an out of network (OON) provider
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met at a different level of 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for anoxic brain injury following a cardiac arrest. The enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding tube. The enrollee has been weaned from the ventilator, but remains in a persistent vegetative state. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B drugs rendered to you on October 10, 2018.You asked the Plan to waive the coinsurance forthese services. You say that it is unfair that the Plan won't pay the coinsurance charge.The Plan denied your request. The Plan says the coinsurance was 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 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. Review of the file shows that you received Part B drugs on October 10, 2018. You have been asked to pay 20% of the cost for these services. These services fall within the Medicare Part B chemotherapy drugs and other Part B 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 forthe Part B drugs rendered to you on October 10, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the orthoses. 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 must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep (95810).
You asked the Plan to pre-approve polysomnography. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that for patients with severe and unambiguous obstructive sleep apnea, the initiation of treatment with nasal CPAP may be incorporated into the diagnostic study night. 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 polysomnography. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation already establishes that the enrollee has both obstructive and sleep apnea, and that the enrollee responds very well to an oral appliance. The documentation also indicates that the enrollee did not tolerate PAP because of a latex allergy, but has not used a non-latex mask. There appears to be no need for a diagnostic sleep study. A titration study for fitting or a non-latex mask or different oral appliance seems reasonable. The requested diagnostic polysomnography (PSG) is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day sensor kit.
You asked the Plan to pre-approve the FreeStyle Libre sensors. You say that you have been using his Freestyle Libre for the last 3 years. You say that you have major kidney failure issues and have been using this machine to monitor your levels all day. You say that you are at high risk without the sensors. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered when certain criteria have been met. We looked at the file and Medicare rules. The progress notes do not list insulin as one of your medications. The Plan shows to have reached out to the provider to confirm that this is the case. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day sensor kit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea prefabricated post and core in addition to a crown (D2954) for tooth # 13.You asked the Plan to pre-approvethe dental service. The Plan denied your request. The Plan says prefabricated post and core in addition to a crown is covered once per tooth every 5 plan years. The Plan also says that the frequency limit for this services has been reached.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 and prefabricated post and core in addition to a crown is listed as a coveredservice, the frequency limit has been reached. The record shows that the Plan previously paid for this service for tooth # 13 on March 4, 2020.Therefore, we decided that the Plan does not have to pre-approvea prefabricated post and core in addition to a crown (D2954) for tooth # 13.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe expanded pharmacogenomic panel provided on October 4, 2019.You asked the Plan to pay forthe expanded pharmacogenomic panel. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that CYP gene panels are not covered.We looked at the file and Medicare rules. In this case, the file shows you billed for an expanded pharmacogenomic panel. These panels should be billed with a single code -CPT 81479. CYP gene panels that test for multiple CYP genes are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the expanded pharmacogenomic panel have not been met.Therefore, we decided that the Plan does not have to pay forthe expanded pharmacogenomic panel provided on October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist, hand orthosis LT, RT (L3916) provided on November 27, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service 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 noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for wrist, hand orthosis LT, RT (L3916) provided on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis RT, LT (L1833) and suspension sleeve RT, LT (L2397) provided on December 20, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records provided do not support the service billed.
The Plan must follow Medicare rules. 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 delivery ticket or a proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid delivery ticket or proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the knee orthosis RT, LT (L1833) and suspension sleeve RT, LT (L2397) provided on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper right quadrant.You asked the Plan to pre-approve the gingival irrigation. You say that the services have been denied because it is not a health reason.The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.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 gingival irrigation is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper right quadrant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).You asked the Plan to pre-approve bone marrow aspiration. You say that this will make spinal fusion more likely to be successful.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental for use in spinal fusion surgery. More research is needed before it can be considered 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 bone marrow aspiration have not been met.Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).