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

We decided that the Plan does not have to pre-approve a genicular nerve block procedure.
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee has no current surgical options and this may be the best option she has for pain relief. The Plan denied your request. The Plan says there is not sufficient evidence to support that this is a useful alternative to surgery.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 57 year old woman has bilateral osteoarthritis of the knee. She is currently taking opiates, Diclofenac gel and Gabapentin for pain. She had an intra-articular steroid injection without sustained benefit. She has not had Physical Therapy or a TENS trial. The request is for bilateral genicular nerve blocks. This is an experimental/ investigational procedure that is the subject of on-going clinical trials and she is not enrolled in a clinical trial. Therefore, the request is deemed not medically reasonable or 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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.You asked the Plan to pre-approve the routine transportation. You say that you were promisedby the Plan that rides to the pharmacy would be covered. The Plan denied your request. The Plan says routine transportation is not covered under your benefit package.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules.The file shows that your benefit packagedoes not have coverage for routine transportation.Therefore, we decided that the Plan does not have to pre-approve routine transportation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device (PCD) to be provided by an out of network (OON) supplier.You asked the Plan to pre-approvethe OON PCD. You say that this specific brand of PCD is not available from network providers and is the only PCD coded as E0651 that can meet the enrollee's needs.The Plan denied your request. The Plan says there is no evidence that a PCD from a network provider would be unable to meet the enrollee's needs.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. There is no specific information provided which shows that a PCD coded the same as the OON PCD which is available from a network provider would be inferior or less effective for this enrollee. 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 the pneumatic compression device (PCD) to be provided by an out of network (OON) supplier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services (CPT 67028 and CPT 92134) provided to the enrollee on September 17, 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 the denied codes remain not supported.
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 67028: Intravitreal injection of a pharmacologic agent CPT 92134: Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina We asked our coding 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 coded correctly. Our coding reviewer found the medical records provided do not include documentation of an Intravitreal injection of a pharmacologic agent (separate procedure) or Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina being performed on September 17, 2019, therefore CPT 67028 and CPT 92134 cannot be verified as being performed on September 17, 2019. We looked at this coder'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 ophthalmology services (CPT 67028 and CPT 92134) provided to the enrollee on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish and gingival irrigation provided on January 7, 2020.
You asked the Plan to pay for the topical application of fluoride varnish and gingival irrigation. You say that your dentist wants you to get periodontal maintenance services 4 times a year. The Plan denied your request. The Plan says topical application of fluoride varnish and gingival irrigation are not covered benefits.
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 pay for the topical application of fluoride varnish and gingival irrigation provided on January 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasounds (76604 and 76881) provided on August 29, 2019. You asked the Plan to pay for the ultrasounds. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed services. 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 76604 is ultrasound, chest (includes mediastinum), real time with image documentation. The CPT Code Manual definition of code 76881 is ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation. We asked our coder 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 ultrasounds. Our reviewer says that CPT code 76604 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation of an Ultrasound, chest (includes mediastinum), real time with image documentation, therefore this service cannot be verified. Our reviewer found CPT code 76881 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation of Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation on the Left or Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation on the RT, therefore these services cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasounds have not been met. Therefore, we decided that the Plan does not have to pay for ultrasounds (76604 and 76881) provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the physician's services. You say that this physician is the only one that can handle your care. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on December 23, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were instructed by a nurse to check into the ER for assessment and received two prescriptions. You say this was not an emergency room thing because it was not an emergency. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $90 copayment per visit for Medicare-covered emergency room visits. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 for the emergency room visit provided on December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on September 4, 2019.You asked the Plan to pay for the orthosis 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.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 enrollee does not meet criteria for the orthosis and sleeve ordered. Our physician reviewer found 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.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 for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on November 27, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the medical records do not support this service.
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. Our reviewer says that the enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a physical examination of the back. 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 have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you were born with flat and badly deformed
feet. You say that you were prescribed orthotics 50 years ago which helped with your knee pains. You were
recently prescribed new orthotics by your treating physician after he told you that the orthotics should be
replaced more often. You say that the orthotics are necessary because they help with your pain and could
prevent a future surgery. You say that it would be a financial hardship for you to have to pay for your own
orthotics which would encourage you to avoid purchasing them. You say this could potentially lead to injury.
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 foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that your existing medical condition directly affects your ability to prevent a return of plantar fasciitis. You suffer from foot drop condition and have had a gradual atrophy of your left calf. You say the combination of these conditions mean that you require the orthotics to help strengthen your tendons. You say that the requested orthotics are necessary to help rejuvenate the plantar fascia.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 foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a modality, unlisted special service, and the x-rays provided from September 3, 2019 to November 1, 2019.
You asked the Plan to pay for the application of a modality, unlisted special service, and the x-rays. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the application of a modality, unlisted special service, and the x-rays provided from September 3, 2019 to November 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not haveto waive the copayment fornon-emergent ambulance services provided on October 12, 2019.You asked the Plan to waive the copayment fornon-emergent ambulance services. You say that you are appealing your cost-share responsibility for the servicesyou 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 show that you received non-emergent ambulance services provided on October 12, 2019. The Medicare-allowed amount for the ambulance services is less than the set $225 copayment; therefore, you have been asked to pay the lesser amount of $223.18 for the ambulance services. 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 fornon-emergent ambulance services provided on October 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Life2000 ventilation assist device (E0466).You asked the Plan to pre-approvethe ventilation assist device. You say that the device is medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ventilation assist device. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has pulmonary fibrosis with severe restrictive lung disease and hypoxic respiratory failure. The order indicates the item being requested is the Life2000 noninvasive ventilation system. This is actually not a ventilator. It is a portable respiratory assist device which is not covered by Medicare, and has not been proven to be beneficial. It is therefore considered notmedically 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 ventilation assist device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Life2000 ventilation assist device (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on June 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 the chiropractic services provided on June 19,2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services rendered from November 21, 2019 to November 23, 2019.
You asked the Plan to pay for these services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 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 these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee presented to the hospital with rectal bleeding. She had comorbidities of chronic obstructive pulmonary disease (COPD), hypothyroidism, cerebrovascular accident (CVA), and congestive heart failure (CHF). She was admitted with diagnosis of an acute gastrointestinal bleed. The records support that the services were necessary and reasonable to meet the enrollee's needs and to improve and maintain the participant's overall health status and were not experimental or cosmetic. 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 been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services rendered from November 21, 2019 to November 23, 2019.