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

We decided that the Plan does not have to pay forlift chairpurchased by the enrollee froma non-participatingprovideron May 15, 2019.You asked the Plan to pay forthe lift chair. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the provider does not accept Medicare.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 provider does not accept Medicare. 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 forlift chair purchased by the enrolleefrom a non-participating provider on May 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix tab 10mg.
You asked the Plan to pre-approve Trintellix tab 10mg. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.
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 Trintellix tab 10mg.
Benefits for Trintellix tab 10mg 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis ultrasound stimulator (CPT E0760).You asked the Plan to pre-approvethe osteogenesis ultrasound stimulator. You say that you are in a lot of pain and are not healing properly.The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of the item in dispute.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 osteogenesis ultrasound stimulator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records provided show a metatarsal small bone foot fracture. Not enough time has passed to establish nonunion.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the osteogenesis ultrasound stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvean osteogenesis ultrasound stimulator (CPT E0760).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing care visit provided on October 4, 2019.You asked the Plan to pay forthe subsequent nursing care visit. You say that the charge was submitted with a "GW" modifier to signify, "Attending physician services not related to the hospice patient's terminal condition." The Plan denied your request. The Plan says Original Medicare is responsible for payment of all Medicare-covered services related or unrelated to the member's terminal illness.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 billMedicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows proof of hospice election from August 16, 2019 to November 13, 2019. Therefore, we decided that the Plan does not have to pay forthe subsequent nursing care visit provided on October 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar decompression surgery.
You asked the Plan to pre-approve spinal surgery. You say that you need this surgery to relieve pain and help you live a more normal life. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because you have not yet tried conservative treatment.
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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show that adequate conservative measures have been tried, and a recent trial and failure of physical therapy has not been conducted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar decompression surgery.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on January 18, 2019 and January 30, 2019.
You asked the Plan to waive the copayments for the ambulance rides. You say that these services should be fully covered because you had no other means of getting to the doctor or rehab. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for Medicare-covered ambulance services per day. You have been asked to pay a $275 copayment for each of the ambulance rides. The ambulance rides 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 the ambulance rides provided on January 18, 2019 and January 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered to the enrollee on August 8, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of procedure code 20999.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 20999 is unlisted procedure, musculoskeletal system, general. We asked our coder 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 these services. Our reviewer says that the submitted records do not support the billing of procedure code 20999. Our coder reviewer found the medical records provided do not include documentation of an unlisted procedure, musculoskeletal system, general, therefore, the service cannot be verified. We looked at this coder'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 pay for the surgical services rendered to the enrollee on August 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that you need more time to recover before going home.The Plan denied your request. The Plan says that your needs are clearly not precluded in an alternate level of care from the SNF setting.The Plan must follow Medicare rules. The rules say thatMedicare 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray provided on September 12, 2019.You asked the Plan to pay forthe panoramic x-ray. You say that you had no way of knowing about the frequency limits. You also say that the provider's office did not call the insurance company so you should not be liable for this bill.The Plan denied your request. The Plan says no more than one full mouth set of x-rays in any 36-month periodis covered. The Plan also says that a complete mandibular denture is not 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, you are limited to 1 panoramic or full mouth x-ray per 36-month period. The record shows that you received a panoramic x-ray on November 28, 2017 and your panoramic or full mouth x-ray benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray provided on September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
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 care can be provided in the current inpatient hospital.
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 ACH, having been admitted with
anemia. The enrollee was found to have colon cancer, for which he underwent surgery. Post-operatively, the
enrollee required intubation/ventilation and he subsequently received a tracheotomy on January 21. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing forthe physician services and medications rendered to you by "the doctor" on August 26, 2019.You asked the Plan to waive the cost sharing forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the cost sharing 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 contractwith the Plan clearly says that you must pay a $40 copayment for specialist's office services and a 20% coinsurance for Medicare Part B covered drugs.Review of the file shows that you received specialist services on August 26, 2019. You have been asked to pay a $40 copayment for these services. These services fall within the specialist's office 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. The file shows that you received an injection of collagenase on August 26, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B covered 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 cost sharing forthe physician services and medications rendered to you by "the doctor" on August 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate for the enrollee.
You asked the Plan to pre-approve Methotrexate. You say that this medication has helped the enrollee. The Plan denied your request. The Plan says Methotrexate to be taken at home is not covered under the 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-approve Methotrexate for the enrollee.
Benefits for Methotrexate 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for noncovered ambulance mileage (A0888) provided on August 17, 2019.
You asked the Plan to pay for noncovered ambulance mileage. You say that you was advised to go to the facility so that you could get specialized care that may not be available at the other facility. You were having excruciating pain and was unable to walk. The Plan denied your request. The Plan says ambulance services is covered to the nearest hospital for the appropriate care. You requested to be transported to the facility. You are responsible for the additional mileage to the requested facility.
The Plan must follow Medicare rules. Medicare rules say that member should be taken to the nearest hospital for care. The enrollee was taken to the facility which is 10.5 miles from the enrollee's home instead of the other facility which is 5.9 miles from the enrollee's home. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of noncovered ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay for noncovered ambulance mileage (A0888) provided on August 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2019 by the out of network provider.
You asked the Plan to pay for anticoagulant management visit. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 the medical services provided on September 3, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve targeted genomic sequence analysis.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis 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 services are not medically necessary. Our physician reviewer found the enrollee has chronic lymphocytic leukemia (CLL of B-cell type) not having achieved remission. The documentation does not support that targeted genomic sequence analysis is medically reasonable and necessary for the enrollee in this case. It is unclear how the targeted genomic sequence analysis will impact the enrollee's management.
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-approvetargeted genomic sequence analysis.The Plan references Local Coverage Determination (LCD) L35024in their determination; however, this LCD does not provide coverage criteria for the services at issue and was not used in the determination.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sleep study for the enrollee.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.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 sleep study 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 services are not medically necessary. Our physician reviewer found the enrollee has mild obstructive sleep apnea (OSA) with a respiratory disturbance index (RDI) of six. He does not haveany contraindications to home positive airway pressure therapy. An attended, in-lab sleep study is therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea sleep study for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve private duty nursing for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the services of a private-duty nurse or other private-duty attendant are not covered. The services at issue are private duty nursing. These services are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve private duty nursing for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics.You asked the Plan to pay forfoot orthotics. You say that your treating physician suggested that you try orthotics to help alleviate your back and foot pain that is cause by arthritis and sciatica. You say that the inserts have helped lessen the pain and have proved beneficial. You asked the Plan to consider payment for the orthotics.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 pay forfoot orthotics.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve endovenous ablation for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation 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 services are medically necessary. Our physician reviewer found the enrollee has both peripheral arterial
arteriosclerosis and venous insufficiency. She has had symptoms for more than three months. She had a trial of
compression stockings. She has limited ability to walk and uses a wheelchair to go shopping. A venous duplex
study on April 19, 2019 showed venous insufficiency. The enrollee meets all of the criteria for coverage of the
requested endovenous ablation and the services are reasonable and 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 been met. Therefore, we decided that the Plan has to preapprove
endovenous ablation for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.