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

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring
system.
You asked the Plan to pre-approve a CGM. You say that with a CGM the enrollee will have better monitoring
and managing of sugar levels. The Plan denied your request. The Plan says criteria is not met for a CGM.
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 record shows the enrollee is not insulin treated with three or
more injections a day, or uses an infusion pump. Based on this information, we decided that Medicare rules for
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a
FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 29, 2019 and billed under codes 95955, 95908, 95885, and 95999.
You asked the Plan to pay for services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says 95941 was approved for payment by the Plan. The Plan states that codes 95955, 95908, 95885, and 95999 were denied because the provider billed procedure codes 95941 x4, 95938-26, 95955-26, 95908-26, 95885-26 x2 and 95999 x4. The Plan states that on December 18, 2019, procedure codes 95941 x4 and 95938-26 were approved and procedure codes 95955-26, 95908-26, 95885-26 x2 and 95999 x4 were as these codes were not supported by the Medical records submitted. The Plan says that the requested codes were not documented in the technical report. The Plan states per Medicare billing guidelines, Train of Four when performed during Intraoperative Neurophysiology Monitoring is inclusive to the Intraoperative Neurophysiology Monitoring. Therefore, these services cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codes and submit medical record documentation to support the services billed. In this case, the claim cannot be fully paid as billed based on the payment relationships or payment inclusivity of certain codes based on the type of service provided. Codes whose payment is included with the billing of another code on the claim cannot be paid separately. Medicare billing criteria for coverage of codes 95955, 95908, 95885, and 95999 are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 29, 2019 and billed under codes 95955, 95908, 95885, and 95999.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on November 17, 2019 to November 24, 2019.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on November 17, 2019 to November 24, 2019.
Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services (97803). You asked the Plan to pre-approve medical nutrition therapy services. You say that you are depressed because you have put on a lot of weight and have tried diets but you don't know how to eat right and your doctor suggested you to go to a nutritionist to help you with your weight. The Plan denied your request. The Plan says the requested service is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services (97803).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that you were told that the orthotics would be covered. You say that you were misquoted by the Plan and if you had known that they would not be covered, you would not have had them made. 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 pay for foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 1, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that it was medically necessary. You say that you were not given a choice of whether the ambulance was in-network. 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 $265 copayment per date of service regardless of the number of ground ambulance trips. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were charged the in-network rate. 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 ambulance transport provided on November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on August 12, 2019. You asked the Plan to pay for this testing. You say that this claim should be paid.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) codes 80307 and G0483 remains not supported. The documentation submitted does not include the method of testing. In order to validate services billed, the order, laboratory report and method of testing should be documented within the medical record; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to the enrollee as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on August 12, 2019 under codes 80307 and G0480
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision by a physical medicine rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services (99215 and 90792) provided on August 12, 2019 through October 28, 2019.You asked the Plan to pay for the outpatient mental health services. You say that you would like reconsideration as you were not aware that this provider was not recognized by Medicare. The Plan denied your request. The Plan says you elected an opt-out provider who is not eligible for payment by Medicare, therefore you are not eligible for reimbursement for services with this provider.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by doctor. This provider has opted out of the Medicare program. The file shows that doctor entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (99215 and 90792) provided on August 12, 2019 through October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 4, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for F2 for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that F2 genetic testing is not considered clinically efficacious. The requested testing is not considered medically reasonable or necessary by Medicare. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for F2 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveOneTouch Ultra Blue test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that the enrollee needs OneTouch Ultra Blue test strips.The Plandenied your request. The Plan says you did not provide documentation that the non-preferred brand of test strips aremedically necessary.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. There is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOneTouch Ultra Blue test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says 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 physician services provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives like Gel-One can be considered.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-One. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason why they would be contraindicated for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe mandibular partial denture. We decided that the Plan does not have to pre-approvethe maxillary partial denture. You asked the Plan to pre-approvethe maxillary partial denture and the mandibular partial denture. The Plan says that the services are not medically necessary.We decided that the Planhas to pre-approvethe mandibular partial denture. 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 mandibular partial denture. Our physician reviewer found the mandibularpartial denture is medically reasonable and necessary. Our reviewer 
found that the supporting abutment teeth #22 and #28 appear to have more than 50% bone remaining and would adequately function with a tooth borne appliance such as the requested metal frame partial denture. Our physician reviewer found that the partial denture would replace a sufficient number of posterior teeth to increase the functional capacity for mastication. Our reviewer also found that given the adequate bone support on the two abutment teeth and apparent need for the replacement of the missing teeth there would be medical necessity for the lower metal frame partial denture. Therefore, we decided that the Plan has to pre-approvethe mandibular partial denture. We also decided that the Plandoes not have to pre-approvethe maxillary partial denture.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-approvethe maxillary partial denture. Our reviewer says that the service is not medically necessary. Our physician reviewer found the abutment teeth #4 and #13 have less than 50% bone remaining. Our reviewer found that the clinical record indicated that the periodontal condition was poor and noted as Stage IV. Our physician reviewer found that in general abutment teeth need to have a 1:1 crown to root ratio in order not to further damage the supporting structures and allow the appliance to function with a good long term prognosis. Our reviewer found that the requested appliance is tooth borne, meaning that the occlusal forces are directed into the supporting teeth and not the tissues. Our physician reviewer also found that the metal frame requested appliance therefore would not be considered medically necessary.Therefore, we decided that the Plan does not have to pre-approvethe maxillary partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy on tooth #5.You asked the Plan to pre-approve the endodontic therapy. You say that you do not want a missing tooth in the front and would like to save the tooth.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve endodontic therapy on tooth #5.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 23, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on October 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from June 25, 2019 through July 1, 2019. You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on June 25, 2019 and discharged on July 1, 2019. You were asked to pay a $320 copayment per day from June 25, 2019 through June 29, 2019, days 1-5 of your inpatient stay. There were no copayment charges from June 30, 2019, day 6 of your inpatient hospital care until your day of discharge July 1, 2019. Per your contract there is a $320 copayment per day required for days 1-5. 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 inpatient hospital care from June 25, 2019 through July 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MTHFR and PAI-1 gene testing (81291 and 81400).
You asked the Plan to pre-approve MTHFR and PAI-1 gene testing (81291 and 81400). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are 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. Medicare specifically states genetic testing for MTHFR (81291) is not covered except for in pregnant patients. The file shows that you are male and are not pregnant. Medicare also states non-lipid biomarkers when used for CV risk assessment are not covered. PAI-1 is not covered in a CV risk assessment panel. Based on this information, we decided that Medicare rules for coverage of MTHFR and PAI-1 gene testing (81291 and 81400) have not been met. Therefore, we decided that the Plan does not have to pre-approve MTHFR and PAI-1 gene testing (81291 and 81400).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 12, 2019 through August 16, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 12, 2019 and discharged on August 16, 2019. You were asked to pay a $195 copayment per day from August 12, 2019 through August 15, 2019, days 1-4 of your inpatient hospital care. You were discharged on August 16, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $195 copayment per day required for days 1-6. 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 inpatient hospital care from August 12, 2019 through August 16, 2019.