Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on April 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that you were not able to get a referral from the enrollee's primary care physician. The Plan denied your request. The Plan says this service was not authorized.

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 an office visit (99213) provided on April 21, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x2), and intravenous moderate sedation
(D9243 x4) provided on April 7, 2021.

You asked the Plan to pay for extractions, and intravenous moderate sedation. You say that you want the Plan
to cover these services. The Plan denied your request. The Plan says you are not covered for these services
when seen by an out-of-network provider.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of extractions, and intravenous moderate sedation have not been met. Specifically, services were
provided by an out-of-network provider without prior authorization.

The Plan has contracted providers available to provide these services. We found no exception that would
require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for
extractions (D7210 x2), and intravenous moderate sedation (D9243 x4) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Global Reach Cancer Genetic Panel (81432, 81479) provided on March 14, 2021.
You asked the Plan to pay for a Global Reach Cancer Genetic Panel. You say that this is supported in the records. The Plan denied your request. The Plan says this was a screening test.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Genetic testing procedures submitted under the code 81432 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. The Global Reach Cancer Genetic Panel was reported in part with code 81432, indicating that it is unlikely to impact therapeutic decision-making, and the record supports that this panel was performed for screening purposes. Therefore, we decided that the Plan does not have to pay for a Global Reach Cancer Genetic Panel (81432, 81479) provided on March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro orthosis (CPT code L8702), for the enrollee.

You asked the Plan to pre-approve the MyoPro orthosis. You say that the MyoPro orthosis is necessary. The Plan denied your request. The Plan says the MyoPro orthosis is not necessary.

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 MyoPro orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro orthosis is considered experimental, investigational and unproven when used to help restore function to arms and hands paralyzed or weakened by cerebrovascular accident (CVA) stroke, brachial plexus injury, cerebral palsy or any other neurological or neuromuscular disease or injury. There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis. The review has determined that the items/services at issue in this case are 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro orthosis (CPT code L8702), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the heart surgery provided on April 5,
2021.

You asked the Plan to waive the coinsurance for the heart surgery. You say that you were told this was a $35
copayment plan. The Plan denied your request. The Plan says that this claim processed 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 20%
coinsurance for surgery services provided in an outpatient hospital.

You have been asked to pay a 20% coinsurance for the heart surgery. The heart surgery falls within the surgery
services provided in 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 coinsurance
for the heart surgery provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on November 19, 2020.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesiology services (00670-QZ) provided on April 19, 2021.

You asked the Plan to pay for code 00670-QZ. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Code 00670-QZ is supported. The medical records provided include documentation that indicates the anesthesia service 00670 was performed with medical supervision (not directed), therefore, the use of a QZ modifier indicating services delivered without medical direction by a physician is appropriate. Therefore, we decided that the Plan has to pay for the anesthesiology services (00670-QZ) provided on April 19, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture.

You asked the Plan to pre-approve the acupuncture. You say that you cannot take medications because of your kidney function is why you need to see the provider for these services. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acupuncture have not been met. Your records do not show that you have low back pain lasting twelve (12) weeks or more. Therefore, we decided that the Plan does not have to pre-approve the acupuncture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown
(high noble metal), tooth #30 (CPT code D6059), for the enrollee.

You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of
services. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pre-approve abutment supported porcelain
fused to metal crown (high noble metal), tooth #30 (CPT code D6059), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 26, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until April 2, 2021. This means that more than one
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan
does not have to pay for the services provided on January 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee (AK), flexible protective outer surface covering system (RT) (CPT code L5964).

You asked the Plan to pre-approve the cover. You say that your current cover is cracked and work out with several holes in the outer protective layer. The Plan denied your request. The Plan says the notes do not show why the requested special cover is needed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cover have not been met. There is no documentation of unusually harsh environmental situations for which a specialized lower limb prosthetic cover is required and for which a standard prosthetic cover would be insufficient. The rules say that the protective outer surface covering systems (L5964) are specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded. They are not for cosmetic or convenience reasons, or for everyday usage in a typical environment. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee (AK), flexible protective outer surface covering system (RT) (CPT code L5964).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73100) provided March 11, 2021.

You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the service has a Column One/Column Two relationship with another code billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 73100 has a Column One/Column Two relationship with code 73110 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (73100) provided March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 18, 2021.
You asked the Plan to pay for the testing. You say that the claim should be reprocessed. The Plan denied your request. The Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit.
The Plan must follow Medicare rules. Medicare rules say that vitamin D assay testing is covered for specific diagnoses. Hypothyroidism is not listed as a covered indication for this testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are currently in the hospital and are ready for discharge. You state you and your family want to continue acute rehab to help you get back to your base line. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of yours nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for vomiting, esophagitis, hyponatremia and pneumonia. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on October 7, 2019.

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 claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. 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
pay for the chest x-ray rendered on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that this is necessary for your recovery. The Plan denied
your request. The Plan says you can be treated in a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the patient does not require treatment by multiple therapies and an intensive
rehabilitation therapy program.

While the patient does require physical and occupational therapy, there is no documented need for an intensive
rehabilitation program. Medically necessary services can be provided in a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the head (70450).

You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 CT scan. Our reviewer says that the
CT scan is not medically necessary. Our physician reviewer found the record indicates that the enrollee was
seen for annual visit and noted to have cognitive impairment over the course of six months. The record
indicates that the neurological examination was non-focal. No laboratory results were available at the time.
There is insufficient evidence to support the requested CT scan.

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 CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve Computed Tomography (CT) of the head (70450).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that step therapy requirements 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 Prolia. Our reviewer says that the criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a a history of osteoporosis-related fracture or a trial of zoledronic acid before they will approve the requested drug. The enrollee has not tried and failed zoledronic acid and has no history of an osteoporosis related fracture. There is no documentation provided indicating that zoledronic acid would likely be less effective or have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wheelchair back cushion provided on
December 11, 2020.

You asked the Plan to waive the copayment for the wheelchair back cushion. You say that you disagree with
your cost share amount. The Plan denied your request. The Plan says that cost share is a contractual obligation
under the plan and cannot be waived.

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 $20
copayment for Durable Medical Equipment (DME) and Related Supplies.

You have been asked to pay a $20 copayment for the wheelchair back cushion. The wheelchair back cushion
falls within the Durable Medical Equipment (DME) and Related 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 copayment for the wheelchair back cushion provided on December 11, 2020.