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

We decided that the Plan does not have to pay forthe speech therapy durable medical equipment (DME) (E2508) provided to the enrollee on May 8, 2020.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.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 does not contain a valid proof of delivery and relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. Therefore, the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe speech therapy durable medical equipment (DME) (E2508) provided to the enrollee on May 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on February 19, 2020, by an OON provider.You asked the Plan to pay forthe subsequent nursing facility care. You say that the doctor was not responsible for getting authorization because the enrollee was in a nursing facility. You also say that the nursing home is responsible for obtaining prior authorization for their enrollees.The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that 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 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 forthe subsequent nursing facility care provided on February 19, 2020,by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory testing (83036) provided on October 1, 2020.You asked the Plan to waive the copayment forlaboratory testing. You say that this should be included inthe office visit.The Plan denied your request. The Plan says this 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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory testing. 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 forlaboratory testing (83036) provided on October 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pay forneurology services (CPT 95907, CPT 95886, CPT 95999) provided to the enrollee on May 27, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe denied codes are not supported in the medical records submitted.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 the denied codes is:CPT 95907:Nerve conduction studies; 1-2 studiesCPT 95886:Needle electromyography, each extremity, with related paraspinal areas, when performed, donewith nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by threeor more nerves or four or more spinal levels (List separately in addition to code for primary procedure)CPT 95999:Unlisted neurological or neuromuscular diagnostic procedureWe 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found in terms of CPT95907, there was no evidence in the records provided that an NCS was performed. Rather the only service provided was stimulation of pedicle screws. This is not consistent with the performance of an NCS (as defined by the CPT manual or technical standards). As no NCS was done, the definition of CPT code 95886 was not met. Rather, while free running EMG was provided, there was no accompanying NCS.Nor was a full EMG study done with a separate report as required by the CPT definition. In terms of CPT 95999, this code 
was probably billed for train of four testing. This service would be otherwise considered to have been billed for/incorporated into the other modalities monitored for. As such this service would not have been eligible for separate reimbursement.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forneurology services (CPT 95907, CPT 95886, CPT 95999) provided to the enrollee on May 27, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing service, miscellaneous (V5299) provided August 19, 2020.You asked the Plan to pay forthe hearing services. You say that you don't understand how to use the benefit if you went to the provider as you were told and this was the option you were provided. They told you it was off list but there was no list.The Plan denied your request. The Plansays the device ordered was not on the formulary and is not covered under the plan benefits.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 the hearing aids are covered when purchased from the designated in-network vendor and limited to twoaids per year, oneaid per ear. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing services have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing service, miscellaneous (V5299) provided August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoCycle Home FES Cycling Therapy system (E0770).

You asked the Plan to pre-approve an FES cycle. You say that the MyoCycle should be approved.The Plan denied your request. The Plan says the records did not establish medical necessity for the requested service.  The Plan must follow Medicare rules. Medicare rules say that items and services that are experimental and investigational are not covered.   

We asked our 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 an FES cycle. Our reviewer says that the requested items/services are not considered reasonable and necessary in this case. Our reviewer found the records show the enrollee has multiple sclerosis. This is not a covered indication.The enrollee's records did not establish medical necessity for the requested service.We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an FES cycle have not been met.Therefore, we decided that the Plan does not have to pre-approve a MyoCycle Home FES Cycling Therapy system (E0770)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtandi.
You asked the Plan to pre-approve Xtandi. The Plan denied your request. The Plan says coverage for the enrollee is limited to Medicare Part B covered drugs. The Plan also says that the enrollee's Part B coverage with the Plan cannot cover this drug.
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 Xtandi.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided.

You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the chiropractic services. 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 chiropractic services provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI provided on May 28, 2020.You asked the Plan to waive the copayment fortheMRI. You say that you were told that an MRI was free. 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 $60 copayment for Medicare-covered complex diagnostic radiological services. You have been asked to pay a $60 copayment for the MRI. The MRI 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 obligationyou agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe MRI provided on May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCxBladder testing (0012M) provided on July 20, 2020.You asked the Plan to pay forCxBladder testing. You say that this is a covered service.The Plan denied your request. The Plan says this service is excluded from coverage.The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met.Therefore, we decided that the Plan does not have to pay forCxBladder testing (0012M) provided on July 20, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea root canal (D3330) to be provided by a Medicare opt out provider.You asked the Plan to pre-approvedental services to be provided by a Medicare opt out provider. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested provider has opted out of the Medicare program. The Plan says there are in-network dental providers available to you that can provide the services you need.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal are not deemed to be for an urgent or emergent situation. The Plan shows there are in-network providers available to you that can provide the services you are requesting.Therefore, we decided that the Plan does not have to pre-approvea root canal (D3330) to be provided by a Medicare opt out provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forComprehensive medication services (H2010) provided on July 10, 2020 to October 8, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medication services. You say that you've been told that you've been denied payment for your services and don't understand why you've been denied. You cannot afford to pay and was told that Medicare and Medicaid can help you.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 had network providers available who could have provided 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 forComprehensive medication services (H2010) provided on July 10, 2020 to October 8, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on September 21, 2020.You asked the Plan to waive the copayment for an ambulance trip. You say that you would like this reduced or waived. You say that you cannot afford this because you are on a fixed income. The Plan denied your request. The Plan says the correct copayment has been 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 an ambulance trip. An ambulance trip 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 for an ambulance trip provided by a participating provider on September 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided by a participating provider on September 29, 2020.You asked the Plan to waive the copayment for cataract surgery. You say thatyou didn't pay anything the first time. You say that you do not think you should owe anything this time either. The Plan denied your request. The Plan says the correct copayment has been 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 $250 copayment for outpatient surgery. You have been asked to pay a $250 copayment for cataract surgery. The correct copayment has been applied to the surgery that was provided. Cataract surgery falls within the outpatient surgery 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 cataract surgery provided by a participating provider on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe two resin-based composites and two periodontal scalings and root planings provided on September 16, 2020.You asked the Plan to pay more forthe resin-based composites and scalings and planings. You say that you feel that these services should be covered.The Plan denied your request. The Plan says this claim was processed correctly.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 responsible for a 50% coinsurance for Class 2 Basic Services.Therefore, we decided that the Plan does not have to pay more forthe two resin-based composites and two periodontal scalings and root planings provided on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a foot pressure off loading/supportive device. You asked the Plan to pre-approve a foot pressure off loading/supportive device (A9283). You say that an ankle boot would not work for you. 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. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of this device. Therefore, we decided that the Plan does not have to pre-approve this foot pressure off loading/supportive device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires (A4557) provided on September 14, 2020. You asked the Plan to pay for lead wires. You say that this is separately payable. The Plan denied your request. The Plan says the replacement of lead wires at this interval is not supported. The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary. We looked at the file and Medicare rules. The record shows that the enrollee received a TENS machine less than 12 months prior to receiving the lead wires at issue. There is no justification in the records as to why it is reasonable and necessary to replace the lead wires at this frequency. Based on this information, we decided that Medicare rules for coverage of lead wires have not been met. Therefore, we decided that the Plan does not have to pay for lead wires (A4557) provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services (H2010) provided on September 14, 2020, by an out-of-network provider.You asked the Plan to pay forthe outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says there were network providers available.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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 foroutpatient mental health services (H2010) provided on September 14, 2020, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra. You asked the Plan to pre-approve Xiidra. You say that there are no acceptable alternative medications for the enrollee's medical condition. You also say that the enrollee has shown significant improvement with Xiidra therapy. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical benefit. The Plan also says that outpatient prescription drugs are not covered. 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 Xiidra.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa (J7323).You asked the Plan to pre-approveEuflexxa. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy device(s), Monovisc. The Plan also says that there is no indication that the Plan's preferred agent(s) would likely be less effective, and/or cause adverse effects for the enrollee.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 Euflexxa. Our reviewer says that Euflexxa (J7323) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Monovisc before they will approve the requested drug. In this case, enrollee has not tried andfailed the required drug(s). Our reviewer also found that there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa (J7323).