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

We decided that the Plan does not have to pre-approve an Alpha-Stim device.
You asked the Plan to pre-approve the requested services. You say that Alpha Stim technology is successful in
the treatment of depression and anxiety. The Plan denied your request. The Plan says your plan only covers
care with providers that accept Medicare.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that you receive your care from a provider who is eligible to provide services under Original
Medicare.
The requested provider in this case is not a network provider with the Plan. The provider is not eligible to
provide services under Original Medicare. We found no exception that would require the Plan to pre-approve
these services. Therefore, we decided that the Plan does not have to pre-approve an Alpha-Stim device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on
December 6, 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 enrollee has previously received the same supplies within the 5-year RUL.
lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when
irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical
condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same durable medical equipment on July 24, 2017. This orthosis is still within the 5-
year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably
damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. Based on this
information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we
decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on
December 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on September 9, 2019 by an out of network provider.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers 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 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 chest x-ray (71046) provided on September 9, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on January 6, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that you disagree with the charges because they were for your annual wellness exam.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 $5 copayment laboratory services. You receivedlaboratory services on January 6, 2020. Laboratory services are not included in annual wellness visits. Therefore, you are responsible to pay the $5 copayment. You have been asked to pay a $5 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 forlaboratory services provided on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra (J0517).You asked the Plan to pre-approve Fasenra. You say that the requested 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 Fasenra. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided the documentation does not support that the Fasenra is medically reasonable and necessary or safe and effective for the enrollee. The records do not indicate that the enrollee has asthma with aneosinophilic phenotype.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fasenra have not been met.Therefore, we decided that the Plan does not have to pre-approve Fasenra (J0517).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe urgent care visit provided on December 11, 2019.You asked the Plan to waive the copayment forthe urgent care visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received services in an urgent care facility on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 $65 copayment for Urgently needed services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received services in an urgent care facility on December 11, 2019. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the Urgently needed services benefit category. This means that you have been asked to pay the correct amount based onyour 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 forthe urgent care visit provided on December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 3 to February 8, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient services were medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
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 submitted documentation does not include admission history and physical, progress notes, or a discharge summary. Without the documentation, medical necessity for inpatient care cannot be determined. 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 February 3 to February 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 25, 2019.
You asked the Plan to pay for the physician's services. 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 physician's services provided on June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve condom catheters (A4349, A4357, A4331).
You asked the Plan to pre-approve the catheters. You say that this request was submitted in order to prevent pressure sores due to incontinence, and to avoid recurrent of urinary tract infection. The Plan denied your request. The Plan says that the records do not show permanent incontinence. The Plan must follow Medicare rules. Medicare rules say that urinary catheters are covered when there is evidence of permanent incontinence. 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 catheters. Our reviewer says that the requested catheters are considered medically reasonable and necessary in this case. Our physician reviewer found the records provide evidence of permanent impairment of urination and permanent incontinence. The records indicate that your overall health has declined so greatly in the past month that you are essentially bedridden. You are unable to ambulate to a bathroom or bedside commode in time to avoid incontinence. You have many permanent and severe medical problems causing this lack of mobility and incontinence, including dementia, stroke, normal pressure hydrocephalus, peripheral neuropathy, and general debility. 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 catheters have been met. Therefore, we decided that the Plan has to pre-approve condom catheters (A4349, A4357, A4331).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 additional treatments of hyperbaric oxygen therapy (HBOT).
You asked the Plan to pre-approve the 20 additional HBOT treatments. You say that the number of HBOT treatments being requested is necessary to prevent morbidity. The Plan denied your request. The Plan says the number of HBOT treatments 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 the 20 additional HBOT treatments. Our reviewer says that the additional number of HBOT treatments are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving HBOT to help heal a compromised skin flap. The health plan agrees that the treatment is warranted, but notes that concomitant review must occur every thirty days to ensure that ongoing treatment is warranted. To that end, the health plan approved services (20 HBOT sessions) to cover thirty calendar days, after which review for ongoing therapy is required. At this time, the additional requested services have not been shown to be medically necessary or reasonable. 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 20 additional HBOT treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve 20 additional treatments of hyperbaric oxygen therapy (HBOT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) and supplies.You asked the Plan to pre-approvea CGM and supplies. The Plan denied your request. The Plan says that this is not covered for your condition.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) and supplies.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on December 7, 2019.
You asked the Plan to pay for the practitioner services. You say that the services were unrelated to hospice care. The Plan denied your request. The Plan says Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice service.
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 practitioner services provided to the enrollee on December 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on February 21, 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 shoulder-hand-wrist orthosis (L3960) provided to the enrollee on February 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower extremity below the knee acrylic socket (L5629) and a lower extremity below the knee suction socket (L5647).
You asked the Plan to pre-approve the lower extremity below the knee acrylic socket and the lower extremity below the knee suction socket. You say that the records provided support the need for the requested items. The Plan denied your request. The Plan says the requested items are not needed for a preparatory prosthesis.
The Plan follows 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 lower extremity below the knee acrylic socket and the lower extremity below the knee suction socket. Our reviewer says that the enrollee does not meet the criteria for coverage of L5629 and L5647 and that these items are not medically necessary. Our physician reviewer found the enrollee is status post left below the knee amputation for osteomyelitis on March 18, 2020. He is noted to be at a K3 functional level. He has been prescribed a preparatory artificial leg with multiple components. In this case, the L5629 and L5647 do not meet Medicare coverage criteria for this enrollee. Medicare does not cover these components for the preparatory artificial leg. There is no compelling rationale or extenuating circumstances presented to support an exception to coverage criteria. 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 lower extremity below the knee acrylic socket and the lower extremity below the knee suction socket have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower extremity below the knee acrylic socket (L5629) and a lower extremity below the knee suction socket (L5647).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan must follow Medicare rules. The rules state that a pneumatic compression device coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met: the enrollee has lymphedema of an extremity as defined above, the coverage criteria for an E0650 or E0651 are met, the enrollee has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. In this instance, the submitted documentation reflects that the enrollee has bilateral lower leg swelling. However, the documentation did not show that the enrollee underwent a 4-week trial using a basic compression pump prior to ordering the advanced pump. In addition, there is no documentation providing the dates of the 4-week trial using the basic pump and the pre and post treatment measurements. As such, proof of a failed 4-week trial has not been shown. In addition, there has been no documentation of measurements of the enrollee's trunk, abdomen or chest indicating that swelling has extended into these areas. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora screening mammogram (77067) and digital breast tomosynthesis (77063) provided on November 15, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe mammography services. You say that the services were medically necessary.The Plan denied your request. The Plan says these services were not emergent. There was no preauthorization and there were network providers 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 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 service at issue. We found no exception that would require thePlan to pay for these services.Therefore, we decided that the Plan does not have to pay fora screening mammogram (77067) and digital breast tomosynthesis (77063) provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on December 26, 2019.You asked the Plan to pay forthe 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay foran ankle-foot orthosis (L1971) provided to the enrollee on December 26, 2019.