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

We decided that the Plan has to pre-approve facet joint injections.
You asked the Plan to pre-approve the requested injections. You say that your pain is preventing you from
turning your head while driving. The Plan denied your request. The Plan says that the records do not show your
pain is localized.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under
certain medical indications.
The file shows that facet injections (CPT Codes 6490, 64491, and 64492) were requested. 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 requested injections. Our physician reviewer found
that you have chronic neck pain and have failed conservative therapy. Your physical exam supports facet
mediated pain with pain on rotation of the neck. There are no radicular findings. The MRI shows facet
arthropathy. There is minimal radiation of the pain and you have failed conservative therapy. Therefore, the
requested procedure is 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 the requested injections have been met. Therefore, we decided that the Plan has
to pre-approve facet joint injections.
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 waive the coinsurance for Medicare Part B drugs provided from July 12, 2019 to August 2, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. 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 a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Part B prescription drugs when purchased through a retail pharmacy and 15% coinsurance for Part B drugs that are administered by a provider. The medical records show that you received an administered Medicare Part B drug on July 12, 2019. The allowed amount is $656.74 and 15% of that is $98.51. The medical records show that you received an administered Medicare Part B drug on August 2, 2019. The allowed amount is $656.74 and 15% of that is $98.51. The total amount you owe is: $197.02. You have been asked to pay the total coinsurance amount of $197.02 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 for Medicare Part B drugs provided from July 12, 2019 to August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for face mask interface, replacement for full face mask provided on July 10, 2019.
You asked the Plan to pay for face mask interface, replacement for full face mask (E0731). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no physician order for the face mask interface.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order for the item at issue in this appeal. The record does not contain a valid physician order for the item provided in this case. Therefore, we decided that the Plan does not have to pay for face mask interface, replacement for full face mask provided on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an inpatient hospital stay at the hospital from January 31, 2019 to February 1, 2019.
You asked the Plan to waive the deductible for an inpatient hospital stay. You say that you cannot afford 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 a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,340 deductible for inpatient hospital care. You had an inpatient hospital stay from January 31, 2019 to February 1, 2019. The record shows that you had paid $0 toward the $1,340 deductible prior to receiving the services. Therefore, you are responsible to pay the deductible amount of $1,340. The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,340 deductible for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time an inpatient hospital stay was received on January 31, 2019 to February 1, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an inpatient hospital stay at the hospital from January 31, 2019 to February 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran MRI provided on September 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for an MRI. You say that you contacted the Plan and you were told that you did not need authorization for the MRI.The Plan denied your request. The Plan says the providing physician is an out-of-network provider. The Plan says that prior authorization is required for out-of-network providers.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 foran MRI provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on February 25, 2019.You asked the Plan to pay forthe ankle foot orthosis (L1971). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says criteria for the orthosis was not 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 pay for the ankle foot orthosis (L1971). Our physician reviewer found the enrollee's chief complaint was ankle pain. The documentation in the case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the ankles and feet. The documentation does not support that this enrollee required stabilization for medical reasons, and had the potential to benefit functionally.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of the ankle foot orthosis (L1971) have not been met.Therefore, we decided that the Plan does not have to pay forthe ankle foot orthosis provided on February 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Libre 14 Day Sensors.You asked the Plan to pre-approveFreestyle Libre 14 Day Sensors. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet Medicare criteria.
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. Medicare guidelines say that in order for an enrollee to be covered for a therapeutic CMG, the above coverage criteria must be met. Medicare says therapeutic CGMs are covered when the enrollee is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. In this case, the file shows that you are not insulin treated with multiple (three or more) daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14 Day Sensors have not been met.Therefore, we decided that the Plan does not have to pre-approveFreestyle Libre 14 Day Sensors
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 19, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to and from a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foroutpatient rehabilitation services and does not have to waive the coinsurance for wrist orthosis provided from August 12, 2019 to August 26, 2019.You asked the Plan to waive the copayments foroutpatient rehabilitation services and to waive the coinsurance for wrist orthosis. You say that you disagree with the charges because you should only owe a $30 copayment per each visit.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 $30 copayment for outpatient rehabilitation services. Your contract with the Plan also clearly says that you must pay 20% coinsurance forprosthetic devices and related supplies.You received outpatient hospital services and wrist orthosis from August 12, 2019 to August 26, 2019. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.  You have been asked to pay the total amount of $202.15for outpatient rehabilitation services and wrist orthosis. Outpatient rehabilitation services falls within the outpatient rehabilitation servicesbenefit category. Wrist orthosis falls withintheprosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments foroutpatient rehabilitation services and does not have to waive the coinsurance for wrist orthosis provided from August 12, 2019 to August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from December 17, 2018 to March 19, 2019.You asked the Plan to pay forthese services. The Plan denied your request. The Plan says that this code is not payable by Medicare.The Plan must follow Medicare rules. The rules say 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. You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan does not offer an additional benefit for this service.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from December 17, 2018 to March 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve sacral lateral nerve branch blocksYou asked the Planto pre-approvethe blocks. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered investigational and experimental.The Plan must follow Medicare rules. Medicare rules say that items and services thatare 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 blocks. Our reviewer saysthat the requested blocks are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure because of the very wide published data on efficacy of this approach. Therefore, the request is considered 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 blocks have not been met.Therefore, we decided that the Plandoes not haveto pre-approvesacral lateral nerve branch blocks
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 9, 2019 by an out ofnetwork (OON) provider.You asked the Plan to pay for physician services. You say that our provider cannot deny any medical services that were essential for patient health treatment while hospital.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan saysthat 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 forphysician services provided on August 9, 2019 by an out of network (OON) provider.
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 enrollee is not able to perform his prior level of independence in tasks of daily living.The Plan denied your request. The Plan says the enrollee's functional level and limited standing tolerance, it is not reasonably expected that the enrollee requires and would significantly benefit from an intensive therapy program.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 physician reviewer found that as of February 12, 2020, the enrollee was at contact guard assist for bed mobility, minimal assist for upper body dressing, moderate assist for lower body dressing, and moderate assist for toileting. He is at maximum assist for activities of daily living. The enrollee is medically stable with no evidence of need for supervision by a physical medicine and rehab physician, or needs acute rehab nursing care. He may benefit from further physical and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on his current functional status.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 carehave not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on February 25, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says criteria for the orthosis was not 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 pay for the shoulder-elbow-wrist-hand orthosis (L3960). Our physician reviewer found the enrollee's chief complaint was shoulder pain. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a credible physical examination of the shoulder.
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 shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on February 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean expandable controller, harness, and electric connection for the enrollee.You asked the Planto pre-approve the accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysit is not medically necessary to control the three approved power options through the joystick (drive interface).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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not indicate use of these accessories will serve to markedly enhance power mobility device function, or improve the enrollee's ability to perform mobility and/or MRADL's. 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 accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean expandable controller, harness, and electric connection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided on August 7, 2019.
You asked the Plan to pay for the neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code 95941-XP has a status code of "I" which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95941 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, CPT code 95941 has a status code of I. This means that 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided on August 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.