Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit and computed tomography (CT) scan of the head or brain provided on August 26, 2019.You asked the Plan to pay for the physician services. You say that the claim has not been paid in full or under the terms of the contract.The Plan denied your request. The Plan says the enrollee's hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the emergency department visit and computed tomography (CT) scan of the head or brain provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive physiologic study of the extremities (93923).
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial as a physiologic study of the extremities is medically necessary. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a primary diagnosis of a history of stroke with associated diagnoses of atrial fibrillation, type 2 diabetes, hypertension, renal insufficiency, chronic heart failure, hyperlipidemia, and anemia. Hyperpigmentation of the feet was noted, although warm, with localized swelling of right foot. No ankle-brachial index (ABI) scores were documented or abnormal ABI noted. Ultrasound carotids and magnetic resonance angiography (MRA) of the brain showed major vessel disease suggesting embolic thrombosis as the cause of the stroke. An abnormal ABI is needed, which is part of a physical examination, prior to justifying additional imaging of the lower extremities with a non-invasive physiologic study of the extremities. As the documentation does not reveal any evidence of a recent abnormal ABI as part of an examination or any other significant findings such as cold feet or absent pulses, this request for a non-invasive physiologic study of the extremities (93923) will be considered 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive physiologic study of the extremities (93923).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone mass measurement testing.
You asked the Plan to pre-approve the requested testing. You say that the enrollee needs a DEXA scan to complete health and wellness. The Plan denied your request. The Plan says the enrollee does not have any conditions indicated for coverage.
The Plan follows Medicare rules. Medicare rules say that bone mass measurement is only covered under certain medical indications. 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 requested testing. Our physician reviewer found that the enrollee has a past medical history of hypertension and diabetes. There is no indication of osteoporosis, pathologic fracture, glucocorticoid therapy or hyperparathyroidism. Based on the rules and medical records provided, the enrollee does not meet the coverage criteria for the requested bone mass measurement. 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 requested testing have not been met. Therefore, we decided that the Plan does not have to pre-approve bone mass measurement testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana for the enrollee. You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication. The Plan denied your request. The Plan says that this is not covered by the Plan. 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 Invokana for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an implant removal (20680) provided on November 7, 2019.
You asked the Plan to waive the copayment for an implant removal. You say that you should not be charged for every surgery. The Plan denied your request. The Plan says this service 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 $325 copayment for surgical services provided in an outpatient hospital facility. You have been asked to pay a $325 copayment for an implant removal, which is a surgical service provided in an outpatient hospital facility 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. You are also liable for the non-covered self-administered drug charge of $8. Therefore, we decided that the Plan does not have to waive the copayment for an implant removal (20680) provided on November 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the implant removal provided on October 31, 2019.You asked the Plan to waive the copayment for the implant removal. You say that it's not your fault the metal case lose. The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for surgical services at an in-network outpatient hospital facility.You have been asked to pay a $325 copayment for the implant removal. The implant removal falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the implant removal provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 31, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 31, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) on tooth #10 provided on February 24, 2020.
You asked the Plan to pay for the crown. You say that you were not able to use the other crown because it broke off. You also say that you cannot afford to pay for the crown. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, crowns, inlays, and onlays are limited to one procedure per tooth every five plan years. The record shows that you received a crown (D2751) on tooth #10 on June 7, 2016 and your crowns, inlays, and onlays benefit for tooth #10 was then exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) on tooth #10 provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services for a drug test provided on November 18, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory 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 laboratory services for a drug test provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 15, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 27, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 81479 is not supported.
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 81479 is unlisted molecular pathology procedure. We find that CPT code 81479 is not supported in the medical record. Specifically, there is no documentation of a further unlisted molecular pathology procedure being performed. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on December 13, 2019.
You asked the Plan to waive the copayment for vision care. You say that you feel that the provider should be considered in-network. 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 $75 copayment for out-of-network vision care. You have been asked to pay a $75 copayment for out-of-network vision care. Vision care falls within the vision care 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 vision care provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided September 17, 2019.You asked the Plan to pay fora pneumatic compression device. You say that you have attached the letter of medical necessity, and doctor prescribing for DVT prophylaxis involving the use of a pneumatic compression device in order to process the claim.The Plan denied your request. The Plan says this device is not covered by Medicare to prevent deep vein thrombosis during or following surgery. Payment for this service would have been included under the facility claim.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0676) provided September 17, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on September 26, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95938 is not supported.
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 95938 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs. We find that CPT code 95938 is not supported in the medical record. Specifically, there is no documentation of a short-latency somatosensory evoked potential study. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox injection (J0585).
You asked the Plan to pre-approve a Botox injection. You say that the medication is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 a Botox injection. Our reviewer says that the medication is not medically necessary. Our physician reviewer found in this case, the enrollee's diagnosis is not included in any Group of ICD-10 Codes that support medical necessity. The review has determined that the documentation does not support that the Botox is medically reasonable and necessary for the enrollee. The documentation does not support that the Botox is safe and effective 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 a Botox injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Botox injection (J0585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 28, 2018 to May 29, 2018.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says the documentation does not support that the criteria for inpatient payment are met in this case.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee presented to the emergency department on 5/28/18 after a witnessed syncopal episode. On evaluation the vital signs were stable and on physical exam she was lethargic with a resting tachycardia. Labs revealed Na 150, blood alcohol 150, lactic acid 4.6 and a magnesium 1.4. The EKG demonstrated sinus tachycardia; the chest x-ray was normal and CT negative for acute findings. She was treated with IV fluids with magnesium and admitted to telemetry. Her condition stabilized and improved and her electrolytes corrected with medical treatment. She was considered medically stable for discharge on 5/29/18 with outpatient follow-up. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 28, 2018 to May 29, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient laboratory services provided on October 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you request reconsideration and approval based on medical necessity. The hospital did not know that the services were not authorized until the services were denied. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to 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 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 inpatient laboratory services provided on October 8, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (Denosumab J0897).
You asked the Plan to pre-approve the Prolia. You say that the enrollee cannot tolerate bisphosphonates. You also say that you recommend that the enrollee be able to do Prolia injections for her osteoporosis. The Plan denied your request. The Plan says the documentation submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Prolia (Denosumab) is not medically necessary. Our physician reviewer found the Plan step therapy requirements require a history of osteoporosis-related fracture or previous treatment, contraindication, or intolerance to Zoledronic Acid. Our reviewer found that the documentation does outline contraindications or reason Zoledronic Acid was not considered. Our physician reviewer found that without the support of the documentation, Prolia is not approved as step criteria is not met. 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 (Denosumab J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 8, 2019.
You asked the Plan to pay for the subsequent nursing facility care. 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 services 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 subsequent nursing facility care provided on May 8, 2019.