Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing provided to the enrollee on July 19, 2019 and billed under code G0483.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria for this testing are not 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 treat illness or disease present in the enrollee at the time of service 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 lab testing provided to the enrollee on July 19, 2019 and billed under code G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 1, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no trial of a lesser device documented.
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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates lymphedema of the abdomen but does not reveal that it has failed to respond to a 4 week trial of conservative therapy or an E0651 pump therefore this request 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay the full amount for the crown, core buildup, and the root canal provided on September 4, 2019.
You asked the Plan to pay the full amount for the dental services. You say that the Plan should have paid for the services. The Plan denied your request. The Plan says that major restorative services and endodontic services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not substantiate their decision about the cost sharing amount that the enrollee is responsible for. The documentation submitted does not show that the Plan has paid the $1,000 maximum allowable of $1,000. Additionally, the documentation does not show the calculations for the cost sharing amounts. Therefore, we decided that the Plan has to pay the full amount for the crown, core buildup, and the root canal provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay the full amount for the porcelain crown (D2740) for tooth # 7 provided on September 10, 2019.
You asked the Plan to pay the full amount for the dental service. You say that you are unable to pay for the crown. You also say that you are in bankruptcy. The Plan denied your request. The Plan says that crowns are not listed as a covered service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not substantiate their decision about the cost sharing amount that the enrollee is responsible for. The documentation submitted does not show the deductible or coinsurance amount for the crown. Therefore, we decided that the Plan has to pay the full amount for the porcelain crown (D2740) for tooth # 7 provided on September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient detoxification treatment.
You asked the Plan to pre-approve inpatient detoxification treatment. You say that the services are necessary since the enrollee has been having withdrawal episodes. The Plan denied your request. The Plan says based on the documentation provided, medical necessity has not been established. Therefore, coverage criteria has not been 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 inpatient detoxification treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided, the admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 9, 2020 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment without any symptoms of withdrawal and awaiting disposition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient detoxification treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient detoxification treatment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laparoscopic tubal cautery (58670).
You asked the Plan to pre-approve a laparoscopic tubal cautery. You say that this is necessary due to the
enrollee's high number of pregnancies. The Plan denied your request. The Plan says this is not covered by
Medicare.
The Plan follows Medicare rules. Medicare rules say that elective sterilization is not covered.
We looked at the file and Medicare rules. The record does not show that the requested sterilization is a
necessary part of the treatment of an illness or injury. Therefore, we decided that the Plan does not have to preapprove
a laparoscopic tubal cautery (58670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 1, 2019 to May 3, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says the inpatient hospital care provided does not meet criteria for coverage.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on April 28, 2019 following a fall. She was diagnosed with a Cervical 2 vertebral fracture. Neurosurgery recommended non-operative management. The documentation states that by day two she was at her neurologic baseline, tolerating a regular diet, had good pain control, and was working with therapy services. She was transferred to an extended care facility on May 1, 2019. She was evaluated by neurosurgery who also recommended non-surgical treatment with no emergent interventions with plans to see in her four weeks. On May 3, 2019 the enrollee was discharged home with a recommendation for outpatient therapy services. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. Inpatient services were not supported by the documentation provided.
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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 1, 2019 to May 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not tried and failed Orthovisc.
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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary. Our physician reviewer found that it is noted that Monovisc has been tried and failed. It is not documented that Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 12, 2018.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 12, 2018.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Accu-Chek Guide Strips.
You asked the Plan to pre-approve Accu-Chek Guide Strips. You say that you were advised the test strips would be covered when you signed up for the plan. The Plan denied your request. The Plan says that a preferred brand must be tried first or your prescriber must state you are unable to use a preferred brand for medical reasons. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that during an enrollee's first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year. We looked at the file and Medicare rules. Specifically, this is your first year of enrollment with this plan. Based on this information, we decided that Medicare rules for coverage of Accu-Chek Guide Strips have been met. Therefore, we decided that the Plan has to pre-approve Accu-Chek Guide Strips.
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the service is necessary. The
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not
been met.
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the
presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or
abnormalities on cardiac testing will be considered screening and denied as not covered by Medicare.
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 myocardial perfusion imaging. Our
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee is noted to
have a history of hypertension, paroxysmal atrial fibrillation and diabetes. In October she underwent an annual
cardiology evaluation. At that visit an electrocardiogram (EKG) was performed. The EKG was thought to be
different from pervious EKGs. Consequently, the evaluating cardiologist ordered and echocardiography
(ECHO) and a stress test. The provided 2013 and 2019 EKGs are different. The enrollee is at risk for silent
ischemia due to her diabetes. Such documentation supports that the requested myocardial perfusion imaging is
medically necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the
Plan has to pre-approve myocardial perfusion imaging.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil 200mg Tablets.
You asked the Plan to pre-approve Modafinil. You say that the medication is medically necessary. The Plan
denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Modafinil 200mg Tablets.
Benefits for Modafinil 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 17, 2019
and billed under codes 72156, 72157 and 72158.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says for codes 72156, 72157 and 72158 the medical records provided include a radiology
report indicating the entry date as April 17, 2019 and an exam date of April 15, 2019 however, the actual date
of service, April 17, 2019, cannot be verified for these codes. The Plan notes that multiple attempts were made
to contact the provider for additional information. Insufficient documentation has been provided to support the
dates of service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code and provide medical records to support the
services billed. In this case, codes 72156, 72157 and 72158 cannot be confirmed for the date of service
reported. The medical records submitted with the claim are insufficient and do not support the services billed.
The Plan indicates additional information, or a corrected claim would be reviewed. Medicare rules for coverage
of this service have not been met. Therefore, we decided that the Plan does not have to pay for physician
services provided to the enrollee on April 17, 2019 and billed under codes 72156, 72157 and 72158.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto 49-51mg tablets.
You asked the Plan to pre-approve the Entresto tablets. You say that the enrollee needs this medication for heart failure. The Plan denied your request. The Plan says the requested oral medication is not covered by Medicare Part B.
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 Entresto 49-51mg tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornurse practitioner services provided on August 31, 2019.You asked the Plan to pay forthe nurse practitioner services. The Plan denied your request. The Plan says there is no valid referral for this service.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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay fornurse practitioner services provided on August 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic surgery for lung resection to be provided by an out of network provider.
You asked the Plan to pre-approve thoracic surgery. You say that your disease has not responded to any medications and has continued to worsen. You say that you contacted the practice for treatment options. You further say that after discussing your condition with a variety of doctors that they agree your surgery should be performed. The Plan denied your request. The Plan says the requested provider is not a network provider under the enrollee's Medicare Cost policy. In addition, the requested service, thoracic surgery, is available with thoracic surgery Plan providers located at the Plan's Medical Centers or with designated plan 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 pre-approve 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. 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 thoracic surgery for lung resection to be provided by the out of network provider.