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

We decided that the Plan does not have to pay for glucose monitoring supplies (K0553) provided on March 24, 2021.

You asked the Plan to pay for glucose monitoring supplies. You say that this was medically necessary. The Plan denied your request. The Plan says there is not a proof of delivery for this item.

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 for the supplies provided in this case. The proof of delivery in the file shows a shipment date of April 1, 2021, and a delivery date of April 4, 2021, neither of which match the billed date of service, March 24, 2021. 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 for glucose monitoring supplies (K0553) provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) provided January 21, 2021.
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the diagnosis code does not substantiate the service.
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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested knee was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. The case file does not contain documentation of knee instability. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) provided January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for DecisionDx-Melanoma test (CPT code 81529) provided to the enrollee on April 8, 2021.
You asked the Plan to pay for the testing. You say that this is a covered benefit under LCD L37725. The Plan denied your request. The Plan says this test is considered experimental/investigational.
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 pay for the testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that DecisionDX-Melanoma is not supported by NCCN guidelines and is considered experimental investigational. The use of this test has not been shown to improve health outcomes in melanoma and is not considered the standard of care. The review has determined that the items/services at issue in this case are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for DecisionDx-Melanoma test (CPT code 81529) provided to the enrollee on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist provided on February 18, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were told that your parent's previous doctor had 
been reinstated to their Plan. The Plan denied your request. The Plan says services were provided by an out-of-
network provider without 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 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. The records provided for review do not show that the services at issue were urgent or 
emergent. 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 an office visit with a specialist provided on February 18, 2021, 
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 for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show that the enrollee is recovering from an acute condition, but the enrollee's illness is not complex enough to require daily physician management and the enrollee does not require specialized nursing services that are only available in an LTACH.
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. LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care.
The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 27, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says 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 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 July 27, 2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy (OT) services provided on August 20, 2020, by an OT assistant (OTA).
You asked the Plan to pay for the OTA services. You say that these services are overseen by the treating provider and should be covered. The Plan denied your request. The Plan says this must be billed with a home health code.
The Plan must follow Medicare rules. Medicare rules say that OTA services must be billed by the supervising therapist and cannot be billed incident-to NPP services since they do not meet the qualifications of a therapist. The file shows that OTA services were provided which were billed by an NPP who is not a licensed therapist. Based on this information, the Medicare rules for coverage of the OTA services have not been met. Therefore, we decided that the Plan does not have to pay for the occupational therapy (OT) services provided on August 20, 2020, by an OT assistant (OTA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half leg (E0673) provided October 27, 2020.
You asked the Plan to pay for the pneumatic appliance. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
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 E0673 is segmental gradient pressure pneumatic appliance, half leg. We find that CPT code E0673 is not supported in the medical record. Specifically, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half leg (E0673) provided October 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on April 7, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that your doctor told you that you needed a colonoscopy and it had been five years since you had had one. You thought this was supposed to be free. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for outpatient surgery. 

Records show that you had a diagnostic colonoscopy due to right lower quadrant pain and constipation. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. Because this colonoscopy was ordered as a diagnostic, not screening, service, it is considered outpatient surgery. 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 diagnostic colonoscopy you had on April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a trial of zoledronic acid or Pamidronate drugs is required before Prolia can be considered.
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 Prolia is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drugs, or any reason they might be unsafe or ineffective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on February 4, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the records show the provider billed the service for February 04, 2021 as a new patient code. The Plan says that Medicare regulations state the new patient procedure codes cannot be billed within three years of the last claim for this service which in the enrollee's case was July 09, 2019. The Plan states a corrected claim with the appropriate code would be reviewed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code new patient code submitted is not valid for use with this physician visit. The Plan states a corrected claim would be reviewed if submitted. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevation feature and expandable controller for a power wheelchair (E2300, E2377).

You asked the Plan to pre-approve the wheelchair accessories.. You say that the features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically necessary. Power Seat elevation features are non-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 the wheelchair accessories. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found there was no documentation showing that the patient requires 2 or more power seat functions to be controlled through a joystick. The power seat elevation feature is not covered under Medicare rules. 

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 wheelchair accessories. have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat elevation feature and expandable controller for a power wheelchair (E2300, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) and supply
allowance provided on March 20, 2021.

You asked the Plan to pay for therapeutic CGM and supplies. You say that the enrollee meets the Medicare
criteria for coverage of this CGM and it is very necessary for the enrollee to improve their quality of life. The
Plan denied your request. The Plan says the denial of payment for these items is correct, because the
documentation did not sufficiently document the medical necessity for these items nor did the billed date of
service match the shipped date or delivery date.

The Plan must follow Medicare rules. Medicare rules say that the Plan may require proof of delivery to verify
that the enrollee received billed DMEPOS items. Medicare rules also state that for shipped items, the date of
service can be the delivery date, shipping date, the date the shipping service label is created, or the date the
item is retrieved for delivery.

We looked at the file and Medicare rules. The date of service billed on this claim does not match the date of
delivery or date of shipping, nor does the documentation support that it matches the date the shipping service
label was created or the date the items were retrieved for delivery. Therefore, the proof of delivery supported
does not support the date of service billed for these items. Based on this information, we decided that Medicare
rules for coverage of therapeutic CGM and supplies have not been met. Therefore, we decided that the Plan
does not have to pay for a therapeutic continuous glucose monitor (CGM) and supply allowance provided on
March 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive eye exam (92014) and intravitreal injection of a pharmacologic agent (67028) provided on November 10, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that you are asking for a one time good faith exception of the prior authorization rule for services rendered. 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 for the comprehensive eye exam (92014) and intravitreal injection of a pharmacologic agent (67028) provided on November 10, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (29999) provided on January 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.
The Plan must follow Medicare rules. Medicare rules say that the complete lists of ASC covered surgical procedures and ASC covered ancillary services, the applicable payment indicators, payment rates for each covered surgical procedure and ancillary service before adjustments for regional wage variations, and wage indices are available on the CMS Web site. We looked at the file and Medicare rules. Code 29999 is not on the list of ASC covered surgical services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services (29999) provided on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter/crutch substitute (E0118).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered based on the clinical information received.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate any weakness. It is unclear why you not able to use crutches. The documentation is not clear that you would be able to safely use the knee walker. Furthermore, the documentation notes a history of low back pain, and is not clear that you have posterior tibial tendor damage, versus an alternative cause such a lumbar radicular symptoms. The documentation does not support a need for this request, as it exceeds your medical 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee scooter/crutch substitute (E0118).
Appeal type: Lab
Decision: Unfavorable


We decided that the Plan does not have to pay for the oncology prostate biochemical assay 4 proteins test (CPT 
code 81539) provided to the enrollee on November 13, 2020. 
 
You asked the Plan to pay for the testing. You say that this test should be covered. The Plan denied your 
request. The Plan says this test is relevant when the enrollee's PSA is between 4 and 10. The Plan states the 
enrollee's PSA is 13.8, this test is not appropriate at this time and cannot be approved. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our physician reviewer found 
the review indicates that review of clinical documentation indicates that the requested test is relevant when the 
enrollee's PSA is between 4 and 10. Member's PSA is 13.8, this test is not appropriate at this time. The medical 
records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the oncology prostate biochemical assay 4 proteins test (CPT code 81539) provided to the enrollee 
on November 13, 2020.