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

We decided that the Plan does not have to pre-approve a stationary compressed gaseous oxygen system (E0424).
You asked the Plan to pre-approve a stationary compressed gaseous oxygen system. You say that this should be covered because the enrollee has chronic obstructive pulmonary disease. The Plan denied your request. The Plan says the requirements for coverage have been met.
The Plan must follow Medicare rules. Medicare rules say that documentation for initial coverage of oxygen equipment requires information in the medical record showing evidence of qualifying test results done within 30 days before the initial date of service We looked at the file and Medicare rules. No medical records have been submitted. Without this information, the medical necessity of the requested item cannot be verified. Based on this information, we decided that Medicare rules for coverage of a stationary compressed gaseous oxygen system have not been met. Therefore, we decided that the Plan does not have to pre-approve a stationary compressed gaseous oxygen system (E0424).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Buprenorphine patch for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage.

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 a Buprenorphine patch for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 20, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve KCNQ1 and KCNQ2 genetic testing.

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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, KCNQ1 and KCNQ2 genetic testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve KCNQ1 and KCNQ2 genetic testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Polysomnography, sleep staging with 1-3 additional parameters of sleep, attended by a technologist (95810) Polysomnography, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist (95811) provided January 18, 2021 to March 9, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you are appealing the cost of a sleep study redo with a copayment of $225 each. You do not believe that it is your fault that you had to retake the test and pay twice the copayment. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $225 copay for each covered diagnostic procedure or test at a network outpatient facility.
You have been asked to pay $450 ($225 x 2) for the diagnostic services. The diagnostic 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 for Polysomnography, sleep staging with 1-3 additional parameters of sleep, attended by a technologist (95810) Polysomnography, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist (95811) provided January 18, 2021 to March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluid circulating cold pad with pump, any type (E0218) provided January 20, 2021.

You asked the Plan to pay for the fluid circulating cold pad with pump. You say that you had a right total knee arthroplasty. The representative was waiting in your room with three medical equipment and collected $150 immediately. You were told the items would come home and PT would set up the machines. The Plan denied your request. The Plan says this service is not medically necessary and is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pay for the fluid circulating cold pad with pump, any type (E0218) provided January 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing services provided by a participating provider on October 1, 2020, to October 24, 2020.

You asked the Plan to waive the copayment for skilled nursing services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $0 copayment per day for days 1-20. There is a $160 copayment for days 21-43 for skilled nursing facility care/in-network. 

You have been asked to pay a $0 copayment per day for days 1-20. There is a $160 copayment for days 21-30 for skilled nursing services. The total amount you are being asked to pay is $1,440 ($160 x days 21-30 = $1,440). Skilled nursing services fall within the skilled nursing facility care/in-network 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 skilled nursing services provided by a participating provider on October 1, 2020, to October 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removable foot insert orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your ankle stiffens with inactivity. 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 removable foot insert orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laser eye surgery received on October 6, 2020.
You asked the Plan to waive the copayment for laser eye surgery. You say that you were told by a representative of the Plan that the laser procedure would be covered. 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 $225 copayment for surgery services at an ambulatory surgical center. You have been asked to pay a $225 copayment for laser eye surgery. Laser eye surgery 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 laser eye surgery received on October 6, 2020.
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6449 and A6504.
You asked the Plan to pre-approve the compression stockings. You say that you are appealing the decision of the plan to deny seamless gloves, arm sleeves and the wrapping due to lack of information. The Plan denied your request. The Plan says fabric supports are not covered by Medicare. The enrollee is not suffering from ulcers, burns or any recent surgical wound that needs compression garments to secure dressings.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6449 and A6504 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. 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. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6449 and A6504.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) on tooth #12.
You asked the Plan to pre-approve the crown on tooth #12. You say that damage was done to your crown and you need it replaced. The Plan denied your request. The Plan says crowns are only covered for posterior teeth.
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. The Plan covers crowns when the services are performed on anterior teeth. We looked at the file, and Medicare rules. The crown is requested to be placed on tooth #12, a posterior tooth. The Plan contract only covers crowns, one every 60 months, per patient, per anterior tooth. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown (D2740) on tooth #12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom Continuous Glucose Monitor.You asked the Plan to pre-approve the Dexcom Continuous Glucose. You say that the Dexcom monitor is medically necessary. The Plan denied your request. The Plan says the record shows no trial of the plan preferred Freestyle monitor.
The Plan must follow Medicare rules. Medicare rules say that may specify brands and manufacturers as preferred. We looked at the file and Medicare rules. The record shows no trial of the plan preferred Freestyle glucometer. The records provided do not include any documentation from the enrollee's physician detailing why the Freestyle meter would be unsafe or ineffective for the enrollee. Based on this information, we decided that Medicare rules for coverage of the Dexcom Continuous Glucose have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom Continuous Glucose Monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like approval for these services to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers available 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 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 physician services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee's need for a skilled level of care is unable to fully assessed.
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. Our doctor found that no medical records have been submitted for review. The health plan appears to have gotten a little bit of information over the phone. The case file shows that the plan requested medical records unsuccessfully from a contract provider. The health plan has not substantiated their denial in this case. As the contract provider is an agent of the plan, it is the plan's responsibility to provide these records. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 pre-approve posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming (64566).
You asked the Plan to pre-approve posterior tibial neurostimulation. You say that this is a non-surgical indirect nerve stimulation in the ankle via the tibial nerve. Clinical notes are attached for review. The Plan denied your request. The Plan says the information rece3ived did not establish the medical necessity of the request.
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 posterior tibial neurostimulation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical information provided does not show that the enrollee has failed standard first and second line treatments. Neurostimulation is considered a third line treatment for overactive bladder.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of posterior tibial neurostimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming (64566).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physician services. You say that you would like approval for these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available 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 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 physician services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.
You asked the Plan to pre-approve Xolair. You say that you need this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of your prescription drug 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 Xolair.Benefits for Xolair 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).

You asked the Plan to pre-approve a continuous glucose monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes with inserts (A5500, A5512) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve diabetic shoes with inserts. You say that the member has uncontrolled diabetes and the shoes with inserts are medically necessary. The Plan denied your request. The Plan says there are in-network providers available 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 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. The records provided for review do not show that the services at issue are urgent or emergent. 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 diabetic shoes with inserts (A5500, A5512) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81436, 81435).
You asked the Plan to pre-approve the genetic testing. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Coverage of molecular testing for Lynch Syndrome for carrier status or family studies is considered screening and is statutorily excluded from coverage and is not a Medicare benefit. We looked at the file and Medicare rules. The record shows no personal history of Cancer. The record does not show a history of more than 20 colon polyps. Testing for familial studies is considered screening and is non-covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81436, 81435).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephonic audio-only evaluation and management (EM) service provided on January 8, 2021, billed with code 99214-UD.

You asked the Plan to pay for the audio-only EM services as billed. You say that this was billed correctly according to the Arizona Medicaid billing rules. The Plan denied your request. The Plan says this was billed with an incorrect date of service.

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, Medicare has established three codes for audio-only visits, 99441, 99442, and 99443. Medicare does not recognize modifier -UD with code 99214 as valid for audio-only EM services. Based on this information, we decided that Medicare rules for coverage of the audio-only EM services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the telephonic audio-only evaluation and management (EM) service provided on January 8, 2021, billed with code 99214-UD.