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

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that the medical documentation provided supports the need for the requested power wheelchair. You say that a power wheelchair will provide the mobility needed to continue with your independence by doing things on your own. You say that you have no mobility device, as it is not safe to continue using your walker. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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.   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 power wheelchair. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has difficulty with mobility related activities of daily living in the home and would benefit from a wheelchair. However, there is no indication that the enrollee would not be able to use a manual wheelchair.  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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Quetiapine Fumarate (J8499).  You asked the Plan to pre-approve Quetiapine Fumarate. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  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 Quetiapine Fumarate (J8499).   Benefits for Quetiapine Fumarate 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chemodenervation services billed with codes 64642, 95874, and J0585 provided on April 21, 2021.  You asked the Plan to pay for the chemodenervation services. You say that the records provided support the codes billed. The Plan denied your request. The Plan says the denied codes remain not supported.  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 64642 is chemodenervation of one extremity; 1-4 muscle(s). The CPT Code Manual definition of code 95874 is needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure). The HCPCS Code Manual definition of code J0585 is injection, onabotulinumtoxina, 1 unit.  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 chemodenervation services. Our reviewer says that the criteria for coverage have not been met. Our reviewer found the documentation does not include that the procedure represented by the codes billed were performed and therefore they cannot be verified.  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 chemodenervation services have not been met. Therefore, we decided that the Plan does not have to pay for chemodenervation services billed with codes 64642, 95874, and J0585 provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary to prevent pain when you walk. 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 foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for a gym membership.  You asked the Plan to reimburse you for a gym membership. The Plan denied your request. The Plan says no additional proof of payment was received.  The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  The Plan's rules for coverage of gym benefits have not been met because no additional proof of payment was received by the Plan. Therefore, we decided that the Plan does not have to reimburse you for a gym membership.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral periapical first radiographic image (D0220) provided on June 16, 2021.  You asked the Plan to pay for a limited oral evaluation and an intraoral periapical first radiographic image. You say that you were unaware the dentist had formally opted out of Medicare. You also say you knew the provider was out of network but not aware that he had opted out. The Plan denied your request. The Plan says the requested provider has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.   The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral periapical first radiographic image (D0220) provided on June 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials provided on March 19, 2021, and April 21, 2021.  You asked the Plan to pay for the additional supplies and materials. You say that this new code was established to report additional practice expenses incurred during a public health emergency and the claims should be reprocessed. 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 March 19, 2021, and April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic mammogram you had on June 25, 2021.  You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this copayment should be waived because you had a needle biopsy, not a mammogram. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that the records confirm that you had a post-procedure diagnostic mammogram on this date of service.  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 $35 copayment for basic imaging services.   You have been asked to pay a $35 copayment for the diagnostic mammogram. We also looked at the medical records to confirm if you had this service.  The records explicitly state that you had a post-procedure mammogram that showed that your mass appeared smaller. The diagnostic mammogram falls within the basic imaging 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 diagnostic mammogram you had on  June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 17, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from January 2, 2021, to January 5, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically reasonable and clinically appropriate. The Plan denied your request. The Plan says that the denial of payment for inpatient level of care is correct, because the enrollee did not meet criteria for inpatient level of care and this stay can be covered as outpatient observation instead.  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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on January 2, 2021 with rib pain after a syncopal event. She was evaluated; initially she was hypotensive but her blood pressure normalized. X-ray and computed tomography (CT) scan of the chest demonstrated rib fractures 8th-10th ribs-no pneumothorax. She was admitted for pain control and therapy services. Her condition stabilized and improved and she was discharged home on January 5, 2021 with outpatient follow-up. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 2, 2021, to January 5, 2021.   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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on July 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered 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 the psychiatric diagnostic evaluation provided on July 15, 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 general health panel rendered on June 8, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code.  You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc (J7325).  You asked the Plan to pre-approve Synvisc. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.  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 Synvisc. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug, Synvisc. Based on the medical records provided the patient has not tried and failed the required drugs. In addition, there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial observation care provided on June 27, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered 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 the initial observation care provided on June 27, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on July 14, 2021.  You asked the Plan to pay for lab tests. You say that this was basic bloodwork you had for an annual wellness visit. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered for screening purposes.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The tests at issue in this appeal, lab tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Restasis.  You asked the Plan to pre-approve Restasis. You say that the enrollee had side effects on other medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  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 Restasis.   Benefits for Restasis 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the immunohistochemistry rendered on November 19, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 88342 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 88342 (immunohistochemistry) and 88187 (flow cytometry). Code 88342 is a column II code with a modifier indicator of 1 when billed with column I code 88187. Code 88342 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry rendered on November 19, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on June 29, 2021.  You asked the Plan to waive the copayment for the breast ultrasound. You say that you were not told that there would be a copayment for this service. The Plan denied your request. The Plan says you were charged this copayment 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 $75 copayment for diagnostic radiology services.   You have been asked to pay a $75 copayment for the breast ultrasound. The breast ultrasound falls within the diagnostic radiology 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 breast ultrasound you had on June 29, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on December 28, 2019.  You asked the Plan to waive the copayment for the ER visit. You say that you were discharged from the hospital and sent home.  You said that a home health nurse was sent out to remove your picc line.  The nurse said that you had to go to the ER to have it removed, so you should not have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment for emergency room visits.   You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the visit. 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 emergency room (ER) visit you had on December 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Gemtesa tablet.  You asked the Plan to pre-approve Gemtesa tablet. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Gemtesa tablet.   Benefits for Gemtesa tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.