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

We decided that the Plan does not have to provide a pneumatic compression device and appliances.
You asked the Plan to provide the Flexitouch pneumatic compression device (E0652) and appliances (E0667). You say that the Flexitouch pneumatic compression device will meet the enrollee's needs. The Plan denied your request. The Plan says the enrollee has not had a four week trial of a basic device.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device and appliances.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833), lumbar-sacral orthosis (L0650) and suspension sleeves (L2397) provided to the enrollee from September 6, 2019 through September 16, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833), lumbar-sacral orthosis (L0650) and suspension sleeves (L2397) provided to the enrollee from September 6, 2019 through September 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram (an EKG) (93005), an x-ray of the esophagus (74220), and emergency room (ER) visitsprovided  from July 13, 2019 through October 31, 2019.You asked the Plan to waive the copayment foran EKG, an x-ray, and ER visits. You say that you are appealing the claim as you feel you have been charged the wrong amounts.The Plan denied your request. The Plan says emergency care services have a $90 copayment per visit,outpatient diagnostic tests (including x-rays and EKGs) have a $45 copayment per date of service.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 $90 copaymentforeachemergency care service,anda $45 copaymentfor outpatient diagnostic tests (including x-rays & EKGs)per date of service.You have been asked to pay a $90 copaymentfor eachER visit,and a $45 copayment for an x-ray of the esophagus($90 + $90+ $45= $225).These services fall within the emergency care services and outpatient diagnostic tests (including x-rays& EKGs) 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 foran electrocardiogram (an EKG) (93005), an x-ray of the esophagus (74220), and emergency room (ER) visits from July 13, 2019 through October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNivolumab (Opdivo).You asked the Plan to pre-approveOpdivo. You say that Nivolumab provides the best tolerated treatment choice, and the only chance to produce a disease response.The Plan denied your request. The Plan says there is no support to use this medicine for the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Opdivo. Our physician reviewer found that you have progressive metastatic cancer of unknown origin. The drug is not FDA approved for the requested use. None of the CMS-approved compendia support the requested use. There are no citations to support the request. The use is not listed as not indicated, not supported or not recommended in any of the compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approveNivolumab (Opdivo).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve palliative home health care services
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no extended prognosis and there are no skilled needs.
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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no wound care issues, or unaddressed medical conditions. There is no recent injury or impairing condition. She has caregivers available to address her physical needs and there would be no reason to think that her condition would deteriorate without ongoing skilled 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve palliative home health care services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 21, 2019 to September 9, 2019 and from September 16, 2019 to September 19, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 21, 2019 to September 9, 2019 and from September 16, 2019 to September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral knee orthoses (L1833), addition to lower extremityorthosis, knee control, condylar pad (L2810) and suspension sleeves (L2397) provided to the enrollee on June 26, 2019.You asked the Plan to pay forthe orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the medical records do not support the 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 pay for the orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and thereis no objective documentation of joint laxity.The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeves have not been met.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1833), addition to lower extremity orthosis, knee control, condylar pad (L2810) and suspension sleeves (L2397) provided to the enrollee on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2019 to September 30, 2019 by an out of network (OON) provider.
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 services were rendered by a non-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 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 4, 2019 to September 30, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forComputed Tomography (CT) of the head and brain(70450) provided on August 12, 2019.You asked the Plan to pay forthe CT scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim at issue is a duplicate of a claim already paid.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 70450 is not supported in the medical record. Specifically, the records provided only support a single procedure. The plan has already paid for the service at issue, the record does not support an additional procedure. Based on this information, we decided that Medicare rules for coverage of theCT scan have not been met.Therefore, we decided that the Plan does not have to pay forComputed Tomography (CT) of the head and brain (70450) provided on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833), addition to lower extremity orthosis, knee control, condylar pad (L2810) and suspension sleeve (L2397) provided to the enrollee on June 17, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the medical records do not support the 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 pay for the orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves and pads were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. There is no documented examination of the knees. The items coded L2397 and L2810 (sleeve and pad) are not separately payable when the base item is not covered. 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 orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833), addition to lower extremity orthosis, knee control, condylar pad (L2810) and suspension sleeve (L2397) provided to the enrollee on June 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services (74018) provided September 3, 2019.You asked the Plan to pay forthe radiology services. You say that the services were medically necessary and properly billed.The Plan denied your request. The Plan says the claim was not correctly 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.We find that CPT code 74018 is not supported in the medical record. Specifically, a 77 modifier would be required to note a second interpretation by another physician on the same service date. The 77 modifier was not attached. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met.Therefore, we decided that the Plan does not have to pay forradiology services (74018) provided September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forvarious services received on August 28, 2019.You asked the Planto pay forthe services. You say that you thought this was a routine preventive visit.The Plandenied your request. The Plansaysthe provider will bill the medical office visit separate from the preventive visit, whenever a medical condition or concern is discussed.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $150 for covered medical services. The item or service you asked the Plan to pay for do not fall within the benefit category of preventive services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $150 for all other services. This cost sharing is a contractual obligation that had not been met at the time the services was received on August 28, 2019.Therefore, we decided that the Plandoes not haveto pay forvarious services received on August 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous device (22869).
You asked the Plan to pre-approve insertion of interlaminar/interspinous. You say that this treatment is medically necessary and appropriate for this stage of the enrollee's disease progression. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the enrollee's health problem. Neither Medicare nor the plan covers this device.
The Plan must follow Medicare rules. Medicare rules say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous device (22869).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on May 14, 2019.
You asked the Plan to pay for the mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider was out-of-network. The services were not emergent or preauthorized. The plan has providers in-network that could have provided these services.
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 outpatient mental health services provided on May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids purchased on September 26, 2019 from an out-of-network provider.You asked the Plan to pay forthe hearing aids. You say that you are requesting reimbursement of services rendered.The Plandenied your request. The Plan says you do not have out-of-network benefits for hearing aids.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, theplan's coverage rules apply in this case. 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 aids have not been met. The provider is not in-network and your EOC clearly states, the hearing aid benefit includes up to two TruHearing hearing aids every year. TruHearinghearing aids include the Advanced and Premium hearing aids offered in an array of colors and styles. The benefit includes a maximum of two hearing aids per year, limited to one ear per year. To access the hearing aid benefit, call TruHearing at 1-855-544-7055 (TTY 711), and a representative will help you set up a hearing exam with a network provider in your area. If hearing loss is discovered, the provider will help you choose and order the right hearing aid(s) for your needs. When the hearing aid(s) is ready, the provider will fit and program it with you in the provider's office.Therefore, we decided that the Plan does not have to pay forhearing aids purchased on September 26, 2019 from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided from September 4, 2018 to September 23, 2019.You asked the Plan to pay forlaboratory services. The Plan denied your request. The Plan says in most cases the care you receive from an out-of-network providerwill not be covered.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 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 for laboratory services provided from September 4, 2018 to September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a fine needle aspiration biopsy (10005) provided on July 19, 2019.You asked the Plan to pay for the biopsy. You say that this claim was submitted with the XS modifier indicating that the physician performed on 2 distinct structures. The Plan denied your request. The Plan says CPT code 10005has the maximum frequency per day of one.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 10005 is not supported in the record. Specifically, CPT code 10005 has a MUE of 1 and MAI of 2. This means that this code has a maximum frequency of once per day. Based on this information, we decided that Medicare rules for coverage of the biopsy have not been met. Therefore, we decided that the Plan does not have to pay for a fine needle aspiration biopsy (10005) provided on July 19, 2019.