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

We decided that the Plan does not have to pre-approve shoe inserts.
You asked the Plan to pre-approve foot orthotics. You say that if you are not able to obtain these inserts, you
will need to have surgery to correct foot problems. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve shoe inserts.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the member does not meet the medical criteria for SNF care.

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 nursing services are not necessary. Our physician reviewer found that there are no identifiable skilled therapy service needs. 

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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental gradient pressure appliance (E0673), provided on July 7, 2021.
You asked the Plan to pay for a pneumatic compression device and segmental gradient pressure appliance. You say that the item is medically necessary. 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 (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 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.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental gradient pressure appliance (E0673), provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92014) and an eye refraction (92015) provided on September 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a medical eye exam and an eye refraction. You say that you did not know that you would not be approved to see the same provider as you did in 2020 for an eye exam. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
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 a medical eye exam (92014) and an eye refraction (92015) provided on September 21, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional unit of surgical services (procedure code 51720) provided to the enrollee on May 14, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the submitted documentation only supports one unit, which was paid and approved.
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 51720 is "Bladder instillation of anticarcinogenic agent (including retention time)." We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the record indicates that the enrollee has a urothelial carcinoma and underwent bladder installation of an anticarcinogenic agent on May 14, 2021. The record does not indicate that two units of service were provided.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of surgical services (procedure code 51720) provided to the enrollee on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epidural Steroid Injections (62323).
You asked the Plan to pre-approve the Epidural Steroid Injections. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections are covered when medically 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 the Epidural Steroid Injections. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found the enrollee had an epidural on December 22, 2021. The review has determined that the requested repeat injections are not medically reasonable or necessary at this time. 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 Epidural Steroid Injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Epidural Steroid Injections (62323).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 7, 2021, to
November 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you were not informed that the services
were not covered. The Plan denied your request. The Plan says no prior authorization was obtained.
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
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for psychotherapy services provided on October 7, 2021, to
November 17, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology exam provided on October 4, 2021, by an
OON provider.
You asked the Plan to pay for the pathology exam. You say that the cost of the laboratory test should have been
covered by the Plan. The Plan denied your request. The Plan says the provider was 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 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
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the pathology exam provided on October 4, 2021, by an OON
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2332) for tooth # 22 provided on September 14,
2021.
You asked the Plan to pay for the dental service. You say that you should not be responsible for this bill. You
also say that you have a $0 copayment. The Plan denied your request. The Plan says 2 fillings are covered per
calendar year with a 50% coinsurance when received in network. The Plan also says that the frequency limit
has been exceeded.
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 and fillings are listed as covered, the
frequency limit of 2 per year has been exceeded. The record shows that the Plan paid for a filling you received
on September 17, 2021, and 1 filling you received on the date of service in this case. Additionally, there is 50%
coinsurance for fillings that are covered. This is a contractual obligation you agreed to when you enrolled in the
Plan's dental coverage.
Therefore, we decided that the Plan does not have to pay for the filling (D2332) for tooth # 22 provided on
September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network provider services rendered to the enrollee on June 3, 2021.

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 the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 out of network provider services rendered to the enrollee on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (CPT code 64484) and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483), for the enrollee.
You asked the Plan to pre-approve the injections. You say that you would like the authorization to be reconsidered and approved. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records do not show documentation of at least 50% sustained improvement in pain for at least three (3) months duration.
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 injections. Our physician reviewer found there is inadequate documentation of the duration and degree of pain relief after each of these epidural injections. The requirement of the LCD is documentation of at least 50% pain improvement for three (3) months. Therefore, at this point, 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (CPT code 64484) and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device placement surgery.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that your condition does not meet criteria for coverage these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device placement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on May 18, 2021.
You asked the Plan to pay for the CGM supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include valid Proof of Delivery [or] a Delivery Ticket to indicate the specific supplies.
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 does not contain a valid proof of delivery. The member did not sign and date a delivery slip indicating the supplier has examined the item. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 12, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.
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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for skin debridement services you received at an outpatient hospital facility from July 13, 2021, to August 20, 2021.

You asked the Plan to waive the copayments for the skin debridement services. You say that the hospital was supposed to be reviewing and correcting your bill. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for dates of service July 20, 2021, and August 20, 2021, the allowed amount for these services ($217.70 per date of service) are less than your copayment obligations, so you are only responsible for the allowed 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 $400 copayment for surgery or other services provided at an outpatient hospital.

You have been asked to pay a $400 copayment for the skin debridement services. The skin debridement services fall within the surgery or other services provided at an outpatient hospital 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 skin debridement services you received at an outpatient hospital facility from July 13, 2021, to August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thoracic epidural steroid injection.
You asked the Plan to pre-approve a thoracic epidural steroid injection. You say that the records provided support the need for the requested injection services for pain control management. The Plan denied your request. The Plan says imaging of the enrollee's thoracic spine was not included in the records provided. The Plan says that the documented examinations did not support thoracic spine pain. The Plan says that the enrollee does not meet the requirements for an epidural steroid injection.
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 a thoracic epidural steroid injection. Our reviewer says that a thoracic epidural steroid injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history that includes chronic lumbar and sacral pain. She has had lumbar radiculopathy to both legs, which is worse with activity and better with rest. At an evaluation on September 28, 2021, the enrollee reported lower back and sacral pain with onset in lower thoracic spine. The pain was described as achy and sometimes a poker-like sensation in the mid back. The enrollee's medical therapy included opiates. She underwent radiofrequency ablation at T10-12 with moderate
relief in past. She had a spinal cord stimulator trial in recent months with a reported relief of pain exceeding 75%. There is no documentation of thoracic radiculopathy. Imaging of the enrollee's thoracic spine was not included in the records 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 a thoracic epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a thoracic epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rivastigmine for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under 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 Rivastigmine for the enrollee.
Benefits for this drug 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management, 30 minutes, (99239) provided on May 5, 2021.
You asked the Plan to pay for the evaluation and management service. You say that the claim was billed correctly. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management, 30 minutes, (99239) provided on May 5, 2021.