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

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you are in pain daily.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (CPT Code 99220) provided to the enrollee on July 26, 2018.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the provider did not submit the claim timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until November 11, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for initial observation care (CPT Code 99220) provided to the enrollee on July 26, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gradient compression sleeve (A6549).You asked the Plan to pre-approve the compression sleeve. You say that you are requesting a reconsideration of the Plan's denial for a custom compression sleeve as other brands do not prevent swelling.The Plan denied your request. The Plan says that the compression sleeve is not covered by Medicare or the health plan.The Plan must follow Medicare rules. The rules say that compression stockings/sleeves described by code A6549 are non covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate for you, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve a gradient compression sleeve (A6549).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 drug testing provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four testing provided to the enrollee on June 3, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the service is considered bundled and is included in the cost of the primary procedure.
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 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 services. Our reviewer says that the operative report indicates that Train of Four Testing was performed. Train of Four Testing is inclusive to the intraoperative neuromonitoring (IONM), whether the IONM is primarily EMG based or MEP based. Therefore, the service is not separately payable. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for Train of Four testing provided to the enrollee on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there is an in-network pain management provider available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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
a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urgent care facility services provided on September 18, 2019 by an out of network (OON) provider. You asked the Plan to pay for the urgent care facility services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care. The Plan states there are in-network urgent care facilities available to you. 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 urgent care facility services provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve epidural steroid injection.
You asked the Plan to pre-approve epidural steroid injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection are covered for certain 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 epidural steroid injection. Our reviewer says that the documentation supports that the requested epidural steroid injection is medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee tried Physical therapy and is taking Norco and Duloxetine. The enrollee's MRI shows an L2-L3 disc protrusion and L4-L5 disc bulge. The documentation shows that the enrollee has radiculopathy and MRI findings that support this intervention. She has failed conservative therapy. Therefore, the enrollee meets criteria for the requested injection services. Review of the file shows that the plan uses LCD L36920 to support their denial. However, LCD L36920 is not valid for the enrollee's home state of Utah. Therefore, we cannot use LCD L36920 to substantiate our decision. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural steroid injection have been met. Therefore, we decided that the Plan has to pre-approve epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant (D6010), abutment supported porcelain/ceramic crown (D6058), and custom fabricated abutment (D6057).
You asked the Plan to pre-approve the endosteal implant, abutment supported porcelain/ceramic crown, and custom fabricated abutment. You say that the endodontic therapy failed, resulting in periapical abscess and vertical bone loss. You also say that in order to restore mastication and speech function, you will need to fabricate a new crown that will fit the abutment of the implant. The Plan denied your request. The Plan says these services are not covered.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant (D6010), abutment supported porcelain/ceramic crown (D6058), and custom fabricated abutment (D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric prosthetic device for the enrollee.You asked the Plan to pre-approve the requested device. You say that traditional rehab strategies have been tried and failed.The Plan denied your request. The Plan says the device has deluxe features that exceed the enrollee's needs.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 requested device. Our physician reviewer found that the requested orthosis is not the most appropriate available supply or level of service for the enrollee considering potential benefits to the enrollee. It is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes for hemiparesis after stroke. The requested device is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the orthosis will improve the long term outcomes for this enrollee, improve her hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Additional controlled studies of the requested device for upper extremity paralysis after stroke are needed with larger patient groups, consistent improvements of relevant outcome functional measures, and long term follow up.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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric prosthetic device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira pen injectors.
You asked the Plan to pre-approve self-administered drugs. You say that this is a continuation of therapy and the enrollee has failed other medications. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B.
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 Humira pen injectors.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab testing services provided to the enrollee on November 14, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no evidence that the provider contacted the plan to verify insurance, current eligibility, or authorization requirements.
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 outpatient lab testing services provided to the enrollee on November 14, 2019.
Appeal type: Outpatient Therapies
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 vascular specialist services. You say that it is medically necessary for the enrollee to undergo treatment. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4921 and D0431). 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 a covered benefit.
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 requested items or services (D4921 and D0431) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D4921 and D0431).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services and does not have to waive the coinsurance for Medicare Part B drugs provided on April 24, 2019.
You asked the Plan to waive the copayment for laboratory services and to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges. 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 $25 copayment for laboratory services provided in an outpatient hospital facility. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received laboratory services on April 24, 2019. Therefore, you are responsible to pay the $25 copayment. You received Medicare Part B drugs on April 24, 2019. The total allowed amount is $2,744.30 and 20% of that is $548.86. The total amount you owe is: $573.86. You have been asked to pay the total amount of $573.86 for laboratory services and Medicare Part B drugs. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 laboratory services and does not have to waive the coinsurance for Medicare Part B drugs provided on April 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services provided
November 27 to November 28, 2019.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment for Emergency Care.
You have been asked to pay a $90 copayment for the Emergency Room Services. The Emergency Room
Services falls within the Emergency 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 Emergency Room Services provided November 27 to November 28, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the coinsurance for outpatient hospital services provided on November 14, 2019.
You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you received inpatient services and disagree with the charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan could not provide medical records in a timely manner. Therefore, we decided that the Plan has to waive the coinsurance for outpatient hospital services provided on November 14, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 30, 2019, to October 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on September 30, 2019, to October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided October 14, 2019 to October 17, 2019.
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary and correctly billed. The Plan denied your request. The Plan says the claim was not submitted correctly.
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 is not supported in the medical record. Specifically, the records show these services were part of a clinic trial, but the claim submitted did not include a clinical trial number. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided October 14, 2019 to October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on December 16, 2019.
You asked the Plan to pay for the orthoses and sleeves. The Plan denied your request. The Plan says that the billed supply code cannot be verified.
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 orthoses and sleeves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these items. 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 the knee orthoses and sleeves provided to the enrollee on December 16, 2019.