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

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that you require the stockings for lower extremity edema.The Plan denied your request. The Plan says gradient compression stockings A6549 are non-covered when there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on October 1, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for a duplex scan. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says the referring provider 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 a duplex scan provided on October 1, 2019 by an
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora 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 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 fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial upper denture (D5213) and 5 additional fillings (D2391).You asked the Plan to pre-approvethe dental services. You say that the enrollee needs to have a denture made in order to properly chew food.The Plan denied your request. The Plan says partial dentures are not listed as a covered service. The Plan says that 1 filling per year is covered. The Plan also says that the frequency limit has been exceeded.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 partial denture is not among those covered under this benefit. Although fillings are listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan approved 1 filling for tooth # 16.Therefore, we decided that the Plan does not have to pre-approvea partial upper denture (D5213) and 5 additional fillings (D2391).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left hip joint capsular injection.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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has complaints of left groin pain after a fall in August of 2019. Imaging showed findings of moderate to severe degenerative changes of the hips. Two weeks after the fall she developed pain radiating from the groin to the left lateral hip and gluteal region distally to the anterior lower leg and to the dorsum of the foot. The standard of care for the enrollee's condition includes conservative treatments of physical therapy, medications, and use of a cane. The requested injection is 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 left hip joint capsular injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CYP panel rendered to the enrollee on October 14, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not billed correctly.The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are non-covered.The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code. Furthermore, this testing is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe CYP panel rendered to the enrollee on October 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 2, 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 knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure (22899 and C9752).
You asked the Plan to pre-approve the Intracept Procedure. You say that this procedure is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says not enough evidence was found to meet medical necessity criteria.
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 Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has not had a diagnostic paravertebral facet joint (median branch) block identifying the paravertebral facet joint as the source of the pain. 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 Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Procedure (22899 and C9752).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 1 power operated vehicle.You asked the Plan to pre-approveaGroup 1 power operated vehicle. You say that you do not use your scooter in the house and the replacement scooter would be for community useand appointments.The Plandenied your request. The Plan says the assessment shows you use a cane or walker for your in-home mobility.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. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a walker orcane. The item at issue in this appealis being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home.This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided thatthe Plan does not have to pre-approvea Group 1 power operated vehicle.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the home health services. You say that you have a condition for which you require assistance doing daily activities. The Plan denied your request. The Plan says there is no doctors order for home care services and no documentation submitted to indicate your need for these services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the records do not show that skilled therapy services or skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you. Our physician reviewer found the documentation does not reveal a physician recommendation for home health services at this time therefore this request is not 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 the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve8 additional physical therapy sessions.You asked the Plan to pre-approvethe additional physical therapy. You say that you would like reconsideration because physical therapy has been helpful.The Plan denied your request. The Plan says the additional physical therapy is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no indication prior physical therapy has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise program.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 additional physical therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve8 additional physical therapy sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve  raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve consultation visit. You say that you want a second opinion with this provider and have other things you would like to consult with this provider.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated within the Plan network.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for clinic services. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.
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 October 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services and an office visit provided on October 25, 2019 and October 30, 2019.
You asked the Plan to waive the copayments for laboratory services and an office visit. You say that you disagree with the charges because this was an annual wellness visit. 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 $40 copayment for labs. Your contract with the Plan also clearly says that you must pay a $20 copayment for primary care provider visits. You received laboratory services on October 25, 2019. Laboratory services are not included in an annual wellness visit. Therefore, you are responsible to pay the allowed amount of $13.79, which is less than the total $40 copayment amount. You received an office visit on October 30, 2019. The record shows that you received services beyond an annual wellness visit. Therefore, you responsible to pay the $20 copayment.
The total amount you owe is: $33.79. You have been asked to pay the total copayment amount of $33.79 for laboratory services and an office visit. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. An office 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 copayments for laboratory services and an office visit provided on October 25, 2019 and October 30, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CPAP battery backup.You asked the Plan to pre-approvea CPAP battery backup. You say that you have frequent power interruptions. The Plan denied your request. The Plan says the supplier must ensure the enrollee's medical needs for the equipment use will be met on a continuous and ongoing basis and have a plan in place to deal with any equipment failure/interruptions that may be life-threatening.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare will not pay separately or make any additional payment for backup equipment.Therefore, we decided that the Plan does not have to pre-approvea CPAP battery backup.
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 the Prolia. You say that this drug is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the member does not meet step therapy exception 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 the Prolia. Our reviewer says that the documentation does not support that the enrollee has tried and failed treatment with Reclast (Zoledronic acid). Our physician reviewer found the documentation does not support that Reclast (Zoledronic acid) would likely be less effective, and/or would likely have adverse effects. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvesuction-assisted lipectomy for the enrollee.You asked the Planto pre-approvethe services. You say that suction-assisted lipectomyThe Plandenied your request. The Plansaysthe clinical information did not that the appearance wascaused by accidental injury, or caused by a malformed body part.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 overall, there is limited medical documentation provided to warrant suction-assisted lipectomy of the lower extremity. It appears that she may have had a previous procedure on 2/7/18; however, there is no recent documentation of any functional impairment related to on enlarged lower extremity.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 pre-approvesuction-assisted lipectomy for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe ambulance transport and emergency room visit provided from December 5, 2019 to December 6, 2019.You asked the Plan to waive the copayments forthe ambulance transport and emergency room visit. You say that you should not be held responsible.The Plan denied your request. The Plan says that the claims processed correctly.Therules 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 $300 copayment for each Medicare-covered ambulance trip and a $90 copayment forMedicare-covered emergency room visits. You have been asked to pay a $300 copayment for the ambulance transport and a $90 copayment for theemergency room visit. The ambulance transport falls within the Medicare-covered ambulance tripbenefit category and the emergency room visit falls within theMedicare-covered emergency room visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 forthe ambulance transport and emergency room visit provided from December 5, 2019 to December 6, 2019.