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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee is using gradient compression sleeve for venous insufficiency and lymphedema. The Plan denied your request. The Plan says the compression stockings are noncovered because they do not meet the statutory definition of a surgical dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that the facility requested that your nurse practitioners see the patient. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that no prior authorization was obtained.
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 physician services provided on November 21, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 800mg Skelaxin.
You asked the Plan to pre-approve the Skelaxin. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Skelaxin is intended for patient self-administration and not covered under Medicare Part B.
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 800mg Skelaxin.
Benefits for the Skelaxin 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 22, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient surgical services. You say that you would like reconsideration because the billed services do not require pre-authorization. The Plan denied your request. The Plan says this claim denied correctly because the provider did not obtain authorization for the services performed. 
 
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 medical services provided on August 22, 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 LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not need to be seen by a physician daily, and does not have complex nursing needs.
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 physician reviewer found that the enrollee is currently undergoing treatment as an outpatient for osteomyelitis of the elbow. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires the level of services provided at a LTACH. Therefore, admission to a LTACH is not currently 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921), localized delivery of antimicrobial agents (D4381 x 4), and the unspecified periodontal procedure (D4999) provided on December 11, 2019.
You asked the Plan to pay for the dental services. You say that you were advised the deep cleaning would cost you $1,500. You also say that you feel you were overcharged for the services. The Plan denied your request. The Plan says gingival irrigation, localized delivery of antimicrobial agents, and unspecified periodontal procedures 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 pay for the gingival irrigation (D4921), localized delivery of antimicrobial agents (D4381 x 4), and the unspecified periodontal procedure (D4999) provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on May 15, 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. 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 a wrist-hand orthosis (L3916) provided to the enrollee on May 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the stockings to reduce swelling in the legs. The Plan denied your request. The Plan says surgical stockings described by codes A4490-A4510 are noncovered for all indications because they do not meet the definition of a surgical dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 12, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says documentation submitted did not support the diagnosis used on the submitted order, nor did the documentation indicate the provider discussed the need for the billed supply code.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician's order indicates the necessity for the supplied code. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the static ankle foot orthosis provided on August 6, 2019 by an out of network provider, Gentle Foot Care. 
 
You asked the Plan to pay for the static ankle foot orthosis (L4396). You say that the enrollee was treated in an attempt to prevent surgical intervention. The Plan denied your request. The Plan says you did not request prior authorization. 
 
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 static ankle foot orthosis provided on August 6, 2019 by an out of network provider, Gentle Foot Care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided by on October 24, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that the visit was unnecessary and the nurse only gave you instructions on how to use the machine. 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 $25 copayment for visits to specialists. You have been asked to pay a $25 copayment for a specialist visit. A specialist 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 a specialist visit provided on October 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on May 25, 2018.You asked the Plan to waive the copayment forthe ambulance transport. You say that you can't pay anything.The Plandenied your request. The Plan says the copayment 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 Planclearly says that you must pay a $250 copayment for Medicare-covered ambulance services.You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls 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 copayment forthe ambulance transport provided on May 25, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you can hardly walk, and are in constant pain. The Plan denied your request. The Plan says you do not require daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our physician reviewer found that from a nursing perspective, you have stable vital signs, your lungs are clear, and you were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a contact guard assist level with functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that your portable oxygen tanks are too heavy. The Plan denied your request. The Plan says you have a home oxygen concentrator and portable oxygen tanks for your needs within your home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The record shows that you have a home oxygen system with refillable portable tanks. This home oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a portable oxygen concentrator. Medicare only covers in-home oxygen needs. You are requesting a portable oxygen system for outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that you will have to go to the nursing home if you don't get the scooter. The Plan denied your request. The Plan says that the information received did not state that you are unable to complete activities of daily living without the aid of a scooter or that you currently are unable to use a cane or walker.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a power scooter. Our reviewer says that a power scooter is not medically reasonable and necessary in this case. The documentation from your physician in January 2020 indicates you ambulate with a rolling walker with seat and is independent in activities of daily living. There is no evidence that your mobility deficit is unable to be helped by the use of a walker or manual wheelchair. There is no detailed gait or neuromuscular exam. There is no evidence of a detailed home evaluation indicating that you can safely navigate this motorized scooter in the home. Our physician reviewer found that your condition does not meet Medicare criteria for a power scooter. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on October 29, 2019. 
 
You asked the Plan to waive the copayment for the EKG. You say that you have never had to pay for these services before. You say that the bill should be adjusted. The Plan denied your request. The Plan says the copayment 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 $10 copayment for diagnostic procedures and tests.  
 
You have been asked to pay $8.52, which is less than the standard $10 copayment for the EKG. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the EKG provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on October 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for the services are included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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. Our reviewer says that that Prolia is not medically reasonable and necessary for the enrollee in this case. The enrollee has not tried and failed Zoledronic acid. The enrollee does not have a history of osteoporotic fracture. The documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that your condition does not meet step therapy criteria for Prolia. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on November 12, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation submitted did not support the diagnosis used on the submitted order, nor did the documentation indicate the provider discussed the need for the billed supply code.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the medical record supports the diagnosis used. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee is legally blind and has significant psoriatic arthritis. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has type II diabetes and is not on insulin. Given that he is not on insulin, the enrollee does not meet the Medicare criteria for coverage and the requested CGM is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.