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

We decided that the Plan does not have to pay for a Flex Foot System for a prosthetic (L5980).
You asked the Plan to pay for the Flex Foot System. You say that the flex foot system is required. The Plan denied your request. The Plan says this is incorrectly coded.
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 L5980 is 'All Lower Extremity Prostheses, Flex Foot System.'
We find that CPT code L5980 is not supported in the medical record. Specifically, as of January 1, 2021 he only products which may be billed using the code L5980 are those for which a written Coding Verification Review has been made by the Pricing, Data Analysis and Coding (PDAC) Contractor and subsequently published on the appropriate Product Classification List. The foot may meet the enrollee's needs and can be reviewed if the approval is subject to correct coding by your prosthetic provider. Based on this information, we decided that Medicare rules for coverage of the Flex Foot System have not been met. Therefore, we decided that the Plan does not have to pay for a Flex Foot System for a prosthetic (L5980).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance transport (A0426), provided on April 30, 2021.
You asked the Plan to waive the copayment for the non-emergency ambulance transport. You say that the service was medically necessary. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way trip for ambulance services. You have been asked to pay a $250 copayment for each one-way trip for the non-emergency ambulance transport. This service falls within the ambulance services 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 non-emergency ambulance transport (A0426), provided on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia, anxiolysis
(D9230).
You asked the Plan to pre-approve the inhalation of nitrous oxide/analgesia. You say that you would like this
service to be reconsidered for coverage. The Plan denied your request. The Plan says this service is not covered
under the enrollee's benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit.
Therefore, we decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia,
anxiolysis (D9230).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that you did not use all of the trips you are allowed. The Plan denied your request. The Plan says you are entitled to a combined total of 120 trips per calendar.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 96 one-way trips per year under your Routine Transportation benefit, and an additional 24 one-way trips per year under your Special Supplemental Benefits for the Chronically Ill.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as not reasonable and necessary. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas Neogen therapy and nutri-pharmaceutical injections billed with CPT codes 97032, 97016, 96372, 97112, J3490, J3420, J3415 and J3411 and provided on September 18, 2020.
You asked the Plan to pay for the Sanexas Neogen therapy and nutri-pharmaceutical injections. You say that you would like reconsideration because the request for repayment was made in error. The Plan denied your request. The Plan says the denial of this therapy was appropriate given the clinical scenario and Medicare guidance.
The Plan must follow Medicare rules. Medicare rules say that for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas Neogen therapy and nutri-pharmaceutical injections have not been met. Specifically, with review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Arizona. Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the Sanexas Neogen therapy and nutri-pharmaceutical injections billed with CPT codes 97032, 97016, 96372, 97112, J3490, J3420, J3415 and J3411 and provided on September 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on
June 3, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you went in for a
routine colonoscopy. You say you did not have to go the hospital. The Plan denied your request. The Plan says
you have been asked to pay 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 $475
copayment for each Medicare-covered outpatient hospital visit or hospital outpatient surgical facility visit.
You have been asked to pay a $475 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy
falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. The record shows a diagnostic code for a benign neoplasm which indicates
the colonoscopy was diagnostic. 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 diagnostic colonoscopy
provided on June 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency transport (A0426 and A0428), provided on April 29, 2021 and May 15, 2021.
You asked the Plan to waive the copayment for the non-emergency transport. You say that the service was medically necessary. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way trip for ambulance services.
You have been asked to pay a $250 copayment for each one-way trip for the non-emergency transport. This service falls within the ambulance services 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 non-emergency transport (A0426 and A0428), provided on April 29, 2021 and May 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power mobility device (PMD) (K0800).
You asked the Plan to pre-approve the power scooter. You say that the group 2 power mobility device should be covered. The Plan denied your request. The Plan says the home evaluation
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the home assessment showed that the doorways of the bedroom and bathroom were not adequately sized to fit the power scooter. This means that Medicare rules for coverage of a PMD have not been met. Once the alterations are made to the doorways, this can be reviewed again. Therefore, we decided that the Plan does not have to pre-approve a group 2 power mobility device (PMD) (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. We looked at the file and Medicare rules. After review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in your State. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. The office visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. 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 provided on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex 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 medical studies have not proven that this device is helpful for treatment of the health problem.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed. 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 the Vertiflex device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional trips. You say that you need additional trips for medical appointments. You also say that you no longer drive. The Plan denied your request. The Plan says 24 one-way trips are covered per benefit period. The Plan also says that the benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic injection 2/1.5 ml for the enrolle.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage.
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 Ozempic injection 2/1.5 ml for the enrolle.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostate rectal spacer (55874).
You asked the Plan to pre-approve a prostate rectal spacer. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that Polyethylene-glycol (PEG) hydrogel is not covered in patients with a prostate volume greater than 80 cubic centimeters. 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 a prostate rectal spacer. Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has prostate cancer, and his prostate volume is 101. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a prostate rectal spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a prostate rectal spacer (55874).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the heart.
You asked the Plan to pre-approve the CT scan of the heart.. You say that this procedure is medically necessary based on the enrollee's family history. The Plan denied your request. The Plan says this procedure is not covered for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that the requested CT scan of the heart is never covered for screening, i.e., in the absence of signs, symptoms or disease. We looked at the file and Medicare rules. In this case, the medical notes indicate that this test is being requested for screening purposes. There are no signs or symptoms that would make this procedure medically necessary. Based on this information, we decided that Medicare rules for coverage of the CT scan of the heart. have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the heart.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zytiga (abiraterone acetate), 250 MG tablet.
You asked the Plan to pre-approve abiraterone acetate. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under 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 Zytiga (abiraterone acetate), 250 MG tablet.
Benefits for abiraterone acetate 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from September 10, 2020, to October 15, 2020.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were told that you would not owe a copayment for the services. 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 $40 copayment for outpatient rehabilitation services.
You received outpatient rehabilitation services from September 10, 2020, to October 15, 2020, for a total of 5 services. You are being asked to pay the total amount of $150, which is less than the total copayment amount. You have been asked to pay the total copayment amount of $150 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 outpatient rehabilitation services provided from September 10, 2020, to October 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on February 27, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes show the kind of precautions taken and the code should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on February 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the specialist office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the specialist office visits. You say that you are in extreme pain and want to see if surgery is an option. The Plan denied your request. The Plan says the provider is out-of-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. The records provided for review do not show that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the specialist office visits to be provided by an out-of-network (OON) provider.