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

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on April 20, 2021.
You asked the Plan to pay for the device. You say that there are many studies that show this device is not experimental and investigational, and rather an industry standard. The Plan denied your request. The Plan says devices billed with E0675 are considered reasonable or necessary.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded with E0675 is used in the treatment of peripheral arterial disease, and will be denied as not reasonable and necessary. If the base device is not covered, then the related accessories will also not be covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the device. Our reviewer says that Our physician reviewer found [state the medical finding(s) upon which the physician based his/her conclusion] 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 pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle skin graft services coded 15738 provided on December 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the muscle skin graft services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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 had network providers available who could have provided 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 muscle skin graft services coded 15738 provided on December 17, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have made slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehabilitation services at the current inpatient rehabilitation facility (IRF) or be stepped down to a lower level of care when appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided April 11, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that you would like these claims 
reprocessed and approved for payment. The Plan denied your request. The Plan says the provider has not 
furnished any documentation supporting the services as billed. 
 
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, there were no medical records provided in this case. 
Without the medical records, we cannot review to see if the services were urgent/emergent or medically 
necessary. It is noted that the Plan has contacted the provider multiple times without a response.  

Therefore, we decided that the Plan does not have to pay for the emergency room services provided April 11, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the semi-electric hospital bed purchased May 5, 2021.
You asked the Plan to pay for the semi-electric hospital bed. You say that the requested semi-electric hospital bed was medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the semi-electric hospital bed is not medically reasonable and necessary. Our physician reviewer found that you do not have a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. You do not have a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. You do not require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain. You do not require the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. You do not require traction equipment, which can only be attached to a hospital bed. The criteria for the semi-electric hospital bed have not been me 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pay for the semi-electric hospital bed purchased May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99233) provided on January 27, 2021, and January 28, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not provided for these services.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation provided does not contain medical records for the dates of service in question. Without records, it cannot be confirmed that Medicare coverage criteria have been met.
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 the services (99233) provided on January 27, 2021, and January 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the medication is 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Retacrit. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that supports that the Retacrit is safe and effective for the enrollee as defined by Medicare criteria as records indicate the intent of the enrollee's chemotherapy is curative. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology consultation to be provided by out-
of-network providers. 
 
You asked the Plan to pre-approve the out-of-network services. You say that this provider is closer to home. 
The Plan denied your request. The Plan says there are providers in-network that can provide the services.
  
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 the 
ophthalmology consultation to be provided by out-of-network providers.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional PT visits. 
 
You asked the Plan to pre-approve six (6) additional PT visits. You say that additional PT is medically 
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 

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 six (6) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally 
accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. 
You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist 
are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. You have been provided additional 
therapy that should be sufficient to ensure proper instruction in a home exercise program. The requested 
services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a 
qualified therapist required to establish, design and/or deliver a program to maintain your current condition or 
to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of six (6) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six (6) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a visual field examination provided on March 22, 2021.
You asked the Plan to waive the copayment for a visual field examination. You say that you feel that the visits should not have been separated into two visits. You feel that the doctor should have given you the results the same day. 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 $50 copayment for specialist services. You received a visual field examination from a specialist on March 22, 2021. Because the visual field examination was performed by a specialist, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a visual field examination. A visual field examination falls within the physician/practitioner services, including doctor's office visits 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 a visual field examination provided on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta (Belimumab) injection (CPT code J0490), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the enrollee has a history of systemic lupus erythematosus (SLE) since 2017 and the enrollee's symptoms are consistent SLE. The Plan denied your request. The Plan says the use of this drug in the enrollee's case requires the enrollee is auto-antibody positive in the absence of any SLE drugs defined as ANA titer greater than or equal to 1:80 OR anti-dsDNA level greater than or equal to 30 IU/mL.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 medication. Our physician reviewer found the enrollee has Systemic lupus erythematosus. The documentation does not support that the member is auto-antibody positive in the absence of any SLE drugs defined as ANA titer greater than or equal to 1:80 OR anti-dsDNA level greater than or equal to 30 IU/mL. The review has determined that the requested use of Belimumab injection is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal.
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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Benlysta (Belimumab) injection (CPT code J0490), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 14, 2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were seen by a physician's 
assistant that was unable to diagnose you and you had to return on a later date for another visit. You feel that 
you should only owe one copayment. 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 $50 
copayment for specialist visits.  
 
The medical records show that you had a specialist visit on June 14, 2021. Therefore, you are responsible to 
pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on June 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. You say that this drug is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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. The criteria for this drug being an oral-antiemetic drug that is covered under Medicare Part have not been met. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an MRI and an ultrasound provided on 
June 29, 2021. 
 
You asked the Plan to waive the copayments for an MRI and an ultrasound. You say that you were told that 
you would only owe a $200 copayment for an MRI and disagree with the additional 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 $200 
copayment for advanced radiology and a $45 copayment for routine radiology.  
 
You received an MRI on June 29, 2021. Therefore, you are responsible to pay the $200 copayment.  
You received an ultrasound on June 29, 2021. Therefore, you are responsible to pay the $45 copayment.  
 
The total amount you owe is: $245.  
 
You have been asked to pay the total copayment amount of $245 for an MRI and an ultrasound. An MRI and 
an ultrasound fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for an MRI and an ultrasound provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast prosthesis purchased March 14, 2021, through April 1, 2021, from a provider not certified with Medicare.
You asked the Plan to pay for the breast prosthesis. You say that you would like to be reimbursed for these items. The Plan denied your request. The Plan says these items are not eligible for payment when purchased from a provider not contracted with Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the breast prosthesis purchased March 14, 2021, through April 1, 2021, from a provider not certified with Medicare.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9338 provided on January 6, 2021.
You asked the Plan to pay for the home infusion therapy 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 payable.
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 S9338 is home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
We find that CPT code S9338 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9338 provided on January 6, 2021.