Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on September 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that since the member is in a nursing facility, the doctor is not responsible to get authorization. The Plan denied your request. The Plan says the referring facility is out-of-network. 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 forskilled nursing services 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 pay forthe wrist x-ray rendered on November 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 73100-59 is not supported.The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the file shows that the enrollee received a wrist exam with two views. The documentation does not support that a separate service was performed. Based on this information, we decided thatMedicare rules for coverage of services billed with a -59 modifier have not been met.Therefore, we decided that the Plan does not have to pay forthe wrist x-ray rendered on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Guardian sensors (A9276).
You asked the Plan to pre-approve Guardian sensors. You say that these are the only sensors that work with the enrollee's pump. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Guardian sensors have not been met. Specifically, the Guardian Sensor (3) glucose values are not intended to be used directly for making therapy adjustments, but rather to provide an indication of when a finger stick may be required. All therapy adjustments should be based on measurements obtained using a home glucose monitor and not on values provided by the Guardian Sensor (3). Therefore, we decided that the Plan does not have to pre-approve Guardian sensors (A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis and sleeve provided to the enrollee on December 23, 2019.You asked the Plan to pay fortheorthosis and sleeve. You say that these items were medically necessary.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 pay for the orthosis and sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The enrollee's chief complaint was recent falls. It is notedthat x-rays demonstrated some arthritis changes in his knee. 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 orthosis and sleeve have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis and sleeve provided to the enrollee on December 23, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on December 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that our laboratory does not collect the specimens. They are collected by the referring physician. The Plan denied your request. The Plan says the referring facility is out-of-network. 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 lab tests provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a inhaler.
You asked the Plan to pre-approve the Trelegy Ellipta. The Plan denied your request. The Plan says the requested medication, is a self-administered drug. The Plan says you have a medical only policy, not a Prescription Drug Plan. The Plan also says drug coverage is limited to Medicare Part B covered drugs.
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 Trelegy Ellipta inhaler.
Benefits for the medicine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy to treat prostate cancer.
You asked the Plan to pre-approve proton beam therapy. The Plan denied your request. The Plan says proton beam therapy for the primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry.
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 proton beam therapy. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Therefore, the requested service is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy to treat prostate cancer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation and bitewing x-rays provided on
October 2, 2019 and October 10, 2019.
You asked the Plan to pay for the gingival irrigation and bitewing x-rays. You say that x-rays are a vital part of
any dental treatment and you do not agree with the frequency limitation. You also say that gingival irrigation
was necessary to prevent further decay of your teeth and for dental hygiene. The Plan denied your request. The
Plan says gingival irrigation is not a covered benefit under your dental plan. The Plan also says that the
bitewing x-rays exceed the frequency limitation in your benefit plan.
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, gingival irrigation is not among those
covered under this benefit. The contract also clearly states that bitewings are limited to one set per plan year.
The record shows that you received bitewing x-rays on October 2, 2019 and your bitewings benefit was then
exhausted. Therefore, we decided that the Plan does not have to pay for the gingival irrigation and bitewing xrays
provided on October 2, 2019 and October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (CPT Code E2310) for a powered wheelchair.
You asked the Plan to pre-approve the electronic connection. You say that without the requested item, the chair will not operate. The Plan denied your request. The Plan says the enrollee is able to control the power tilt through its own switch. There is no need to control this power option through the joystick.
The Plan follows Medicare rules. Medicare rules say that wheelchair options are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the electronic connection. Our physician reviewer found that you have a below-knee amputation. You still need some assist for certain activities of daily living. There is no indication your wheelchair could not safely, and adequately function without this accessory. It is not necessary for PMD operation and is a convenience item. As such, it is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (CPT Code E2310) for a powered wheelchair.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on November 13, 2019.
You asked the Plan to pay for the physician service. You say that the claim was denied despite using the appropriate modifier. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug and does not have to waive the copayment for an X-ray provided on October 29, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug and to waive the copayment for an X-ray. 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 aplan 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 20% coinsurance for Medicare Part B prescription drugs.Your contract with the Plan also clearly says that you must pay a $15 copayment for basic radiological services provided in a specialist's office.You received a Medicare Part B drug on October 29, 2019. The allowed amount is $11.69 and 20% of that is $2.34. You received an X-ray on October 29, 2019. Therefore, you are responsible to pay the $15 copayment. The total amount you owe is: $17.34.  You have been asked to pay the total amount of $17.34 for a Medicare Part B drug and an X-ray. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. An X-ray 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 coinsurance fora Medicare Part B drug and does not have towaive the copayment for an X-ray provided on October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nebulizer with compressor provided on July 16, 2019 by out-of-network provider.You asked the Plan to pay forthe nebulizer with compressor (E0570). You say that the nebulizer was medically necessary.The Plan denied your request. The Plan says you did not request 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 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 forthe nebulizer with compressor provided on July 16, 2019 by out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea panniculectomy procedure.You asked the Plan to pre-approvethese services. You say that you are getting skin infections.The Plan denied your request. The Plan says the services are not medically necessary.ThePlan must follow Medicare rules. Medicare rules say that a panniculectomy 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 services are not medically necessary. Our physician reviewer found the submitted records show that you had bariatric surgery with significant weight loss. You have complaints of chronic rashes underneath an overhanging pannus. You have been treated with typical dermatological management. The Medicare rules require a specific amount of time following weight loss from bariatric surgery to pass before a panniculectomy can be considered. It has been less than 24 months from your surgery and it is not clear that the weight loss has been stable for six months. The panniculectomy is 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-approvea panniculectomy procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvereduction mammoplasty.You asked the Plan to pre-approvereduction mammoplasty. You say that without this surgery would could be put in the hospital or worse.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this request is cosmetic in nature. The Plan follows Medicare rules. Medicare rules say that reduction mammoplasty is only covered under certain specific indications. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.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 reduction mammoplasty. Our reviewer says that you do not meet the Medicare criteria for the requested mammoplasty. Our physician reviewer found there is insufficient medical documentation that correction of your breast ptosis would likely improve your functional impairment of neck and upper back. You do have evidence of other functional impairment, including chronic rashes, however, the time course of this occurrence and treatment are lacking. You have attempted to correct these rashes with over-the-counter treatment, but treatment with standard dermatologic management has notbeen adequately specified.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of reduction mammoplasty have not been met.Therefore, we decided that the Plan does not have to pre-approvereduction mammoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forvision services provided on October 22, 2019.You asked the Plan to waive the copayment forvision services. You say that you disagree with the charges because this was routine.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 $45 copayment for vision care. The medical records show that you received visioncare beyond routine services on October 22, 2019. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for vision services. Vision services fall within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forvision services provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2740) for tooth #16 and core buildup, including any pins when required (D2950) for tooth #16.You asked the Plan to pre-approvethe crown and core buildup. You say that tooth #16 needs urgent attention by the dentist. You also say that the condition of the molar shows rugged edges and also showing that part of the molar has broken off.The Plan denied your request. The Plan says the records do not support the need for these services.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 the crown and core buildup when the services are medically necessary and reasonable. 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 crown and core buildup. Our reviewer says that the services are not medically necessary. Our physician reviewer found due to the fact that tooth #16 does not appear functional since there is no opposing tooth in occlusal contact, the restoration with a crown and core buildup does not meet the criteria for coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown and core buildup have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown (D2740) for tooth #16 and core buildup, including any pins when required (D2950) for tooth #16.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99238) provided on October 3, 2019.You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration because the member was placed in observation and monitored for a safe discharge after an outpatient procedure.The Plan denied your request. The Plan says the CPT code billed is not appropriate for the place of service submitted.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99238 is hospital discharge day management; 30 minutes or less. We find that CPT code 99238 is not supported in the record. Specifically, it is not appropriate to report CPT code 99238 with an outpatient POS code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99238) provided on October 3, 2019.