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

We decided that the Plan does not have to pre-approveXopenex for the enrollee. You asked the Plan to pre-approveXopenex. You say that the enrollee is having ongoing symptoms requiring the use of a rescue inhaler.The Plan denied your request. The Plan says Xopenex to be taken at home is not covered under the Part B benefit.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-approveXopenex for the enrollee. .Benefits for Xopenexmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upgrade to a Dexcom G6 continuous glucose monitor.
You asked the Plan to pre-approve a Dexcom G6 continuous glucose monitor. You say that your doctor recommended the Dexcom G6 because it needs to be filled less frequently. The Plan denied your request. The Plan says your current CGM is meeting your needs.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. Your current CGM was approved on January 29, 2019 and is in working order. This CGM is still under reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve an upgrade to a Dexcom G6 continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 1, 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 progress notes were not submitted in order to determine the clinical utility of the testing.
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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found submitted documentation included only an order requisition and laboratory results. There are no provider or progress notes outlining medical history or rationale for laboratory testing. Without the support of the documentation, medical necessity 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on February 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral lumbar medial branch block injections (64493 and 64494).You asked the Plan to pre-approvebilateral lumbar medial branch block injections (64493 and 64494). You say that the requested bilateral lumbar medial branch blocks are medically necessary.The Plan denied your request. The Plan says the requested bilateral lumbar medial branch blocks do not meet criteria.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bilateral lumbar medial branch block injections (64493 and 64494). Our reviewer says that the requested bilateral lumbar medial branch blocks do not meet criteria. Our physician reviewer found the enrollee is with a history of low back pain due to lumbosacral spondylosis. The pain management provider recommended a 2nd set of diagnostic facet medial nerve branch blocks (MBB's) bilaterally at the L3-4, L4-5 and L-5-S1 levels. On 1/16/2020, the enrollee underwent bilateral diagnostic facet medial nerve branch blocks bilaterally at the L3-4, L4-5 and L5-S1 levels. The member reported more than 90% pain control for 5-6 hours before the pain returned. However, the information received did not show continued conservative therapies for at least 3 months. The review has determined that the enrollee did not have a covered indication for the requested bilateral lumbar medial branch blocks as requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral lumbar medial branch block injections (64493 and 64494) have not been met.Therefore, we decided that the Plan does not have to pre-approvebilateral lumbar medial branch block injections (64493 and 64494).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit provided on October 7, 2019.
You asked the Plan to pay for specialist visit. You say that the enrollee has seen other providers in your physician group practice; however, these providers are not of the same office nor specialty. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this claim processed under the same group identification record as previous claims.
The Plan must follow Medicare rules. Medicare rules say that, for the purposes of selection of evaluation and management visit codes, a new patient is a patient who has not received and professional services from the physician or physician group practice (same physician specialty) within the previous 3 years. We looked at the file and Medicare rules. The record does not show that the enrollee had received any professional services from the doctor or a physician of the same physician specialty in the same physician group practice within 3 years prior to the visit on October 7, 2019. Therefore, the Plan has not shown that its denial on this basis is correct or justified according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of specialist visit have been met. Therefore, we decided that the Plan has to pay for an office visit provided on October 7, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
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 August 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for 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 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 August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are necessary because they reduce swelling in your legs. The Plan denied your request. The Plan says you do not have a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. We looked at the file and Medicare rules. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Based on this information, we decided that Medicare rules for coverage of the compression stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued SNF services after January 10, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee still needs services from a SNF. The Plan denied your request. The Plan says that according to the records, the enrollee is not likely to improve significantly with a continued stay at skilled rehab.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 10, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued SNF services after January 10, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forlaboratory services provided  from September 27, 2019 to October 1, 2019.You asked the Plan to waive the copayments forlaboratory services. You say that you disagree with the charges because the provider messed up the first laboratory test.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 $10 copayment for laboratory tests.You received laboratory services on September 27, 2019 and October 1, 2019. Therefore, you are responsible to pay a $10 copayment per each laboratory service. The total amount you owe is: $20.00. You have been asked to pay the total copayment amount of $20.00 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 copayments forlaboratory services provided from September 27, 2019 to October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0652).
You asked the Plan to pre-approve the intermittent limb compression device. You say that the enrollee requires the device due to lymphedema. 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. Medicare rules say 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. We looked at the file and Medicare rules. In this instance, the submitted documentation reflects that the enrollee has bilateral lower leg swelling that has not been improved with compression garments, leg elevation and the use of diuretics. However, the documentation did not show that the enrollee underwent a 4-week trial using a basic compression pump prior to ordering the Flexitouch 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 the intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has diabetes treated with one basal insulin injection per day. She tests blood sugar levels four times a day. She does not meet the criteria for coverage for the therapeutic CGM. The requested CGM is therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a second opinion. You say that this provider specializes in the cancer treatment that is needed. The Plan denied your request. The Plan says there is an in-network provider that has the same certification as the physicians nearby and also specialize in treating cancer.
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 second opinion to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on September 24, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthese codes represent a statutory exclusion.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 the denied codes is:CPT 81230:CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22)CPT 81231:CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism),gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7)We find that CPT code  is not supported in the medical record. Specifically, both of these codes have a status code of X, which means that these codes are a statutory exclusion. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea custom breast prosthesis.You asked the Plan to pre-approvea custom breast prosthesis (L8035). You say that because of amedical condition the enrollee needs a custom breast prosthesis.The Plandenied your request. The Plan says Medicare guidance says a custom breast prosthesis is not better than a prefabricated breast prosthesis and therefore not covered.The Plan must follow Medicare rules. Medicare rules say that for any item to be coveredby Medicare it must meet all other applicable Medicare statutory and regulatory requirements.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a custom breast prosthesis (L8035) have notbeen met.Therefore, we decided that the Plan does not have to pre-approvea custom breast prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), wrist hand orthosis (L3916) and suspension sleeve (L2397) provided to the enrollee on August 13, 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 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.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), wrist hand orthosis (L3916) and suspension sleeve (L2397) provided to the enrollee on August 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit provided on September 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient office visit. You say that you would like the Plan to reconsider our claim for processing and payment based on medical necessity. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient office visit provided on September 20, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 10, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that the scan was not performed correctly. You say that repeat scans would not have been done if the service was completed correctly. 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 $75 copayment for each visit for the following Medicare-covered diagnostic radiology procedures: computed tomography (CT), magnetic resonance (MRI's and MRA's), and nuclear medicine studies, which includes PET scans. You have been asked to pay a $75 copayment for the CT scan. The CT scan falls 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 for the CT scan provided on September 10, 2019.