Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on August 6, 2020.

You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered. 

We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0013M) provided on August 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for detoxification visit. You say that there was no time to submit a prior authorization request as this happened overnight, and you were under the impression that the Plan would cover this treatment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 medical services provided on August 20, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS non-ambulance services (A0428) and ground mileage (A0425) provided August 13, 2020.

You asked the Plan to pay for the ambulance services. You say that an in-network provider was unable to transport the enrollee on the date of service. The enrollee was being taken back to their residence after a necessary doctor's appointment. The Plan denied your request. The Plan says ambulance transport to/from a physician's office/clinic/outpatient center is not a covered destination.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. 

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for BLS non-ambulance services (A0428) and ground mileage (A0425) provided August 13, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation.

You asked the Plan to pay for the radiofrequency ablation. You say that you would like reconsideration because you have horrible back pain and this procedure will provide you with relief. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation have not been met. Specifically, per the LCD, this is not a covered benefit. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150) and the unspecified preventive service (D1999) provided on September 23, 2020.

You asked the Plan to reimburse you for the dental services. You say that you need to be reimbursed. You say that you have tried to call many times. You also say that you still have not received a refund. The Plan denied your request. The Plan says 1 comprehensive oral or 1 periodontal evaluation every 3 calendar years. The Plan says that the frequency limit has been exceeded. The Plan also says that additional payment will not be made for the unspecified preventive service as a separate monthly stipend is being provided.

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 frequency limit for the comprehensive oral evaluation has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on September 9, 2019. Additionally, the unspecified preventive service is not covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150) and the unspecified preventive service (D1999) provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 10, 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 the claim was billed incorrectly.

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 outpatient rehabilitation setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on November 12, 2020.

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because your primary care was not available to see you and recommended that you go to the hospital. 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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the elbow orthosis (L3760) provided on July 2, 2020.

You asked the Plan to pay for the elbow orthosis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not processed because an incorrect place of service was used.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report the correct place of service. 

In this case, the place of service that the provider reported was "11" or office. For durable medical equipment, the place of service that must be reported is where the enrollee will be using the equipment. Based on this information, we decided that Medicare rules for coverage of the elbow orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the elbow orthosis (L3760) provided on July 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided from September 4, 2020, to
September 25, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the
member's primary care physician did not refer these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 outpatient services provided from September 4,
2020, to September 25, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (K0800).

You asked the Plan to pre-approve the power operated vehicle. You say that you would like reconsideration
because you have knee pain and the scooter will help you to get to the mall, the store and around your
daughter's house. The Plan denied your request. The Plan says this scooter is being requested for use outside
the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a power operated vehicle (K0800).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 17, 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 the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on June 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100mg Pregabalin capsules.

You asked the Plan to pre-approve the Pregabalin. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this medication does not fall 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 100mg Pregabalin capsules.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says custodial care is not covered.

The Plan must follow Medicare rules. The rules say that for home health aide services to be covered, the services provided by the home health aide must be part-time or intermittent. The file shows that home health aide services were requested for 8 hours a day, 7 days a week. We looked at the file, and Medicare rules. Home health aide services are only covered when they are either part-time or intermittent.

The records do not show that skilled care was also requested. Home health aide services are not covered without skilled services. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says a 3 month-supply will be approved and then re-evaluated.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

The file shows that the plan approved 3 months of services. We looked at the file and Medicare rules. No more than 3 months of supplies is approved at a time without further evaluation. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve additional continuous glucose monitor supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says services can be obtained at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that as of February 25, 20201 you require custodial 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 SNF care have not been met. Specifically, the care you are required to obtain is custodial and is not covered under Medicare. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on October 20, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 nurse practitioner 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 nurse practitioner services provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 28, 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 the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal, a molecular genetic screening, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the laboratory services rendered on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 99202) provided to you on October 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue (CPT 99202) is not manual manipulation of the spine. Please note that you have no liability for CPT 98940. Therefore, we decided that the Plan does not have to pay for the chiropractic services (CPT 99202) provided to you on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient consultation (99252) provided on August 11, 2020.

You asked the Plan to pay for an inpatient consultation. You say that this is supported in the records. The Plan denied your request. The Plan says this code is not valid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99252 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient consultation (99252) provided on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued tumor treatment field therapy (TTFT) for the
enrollee.

You asked the Plan to pre-approve continued TTFT. You say that this is the standard of care. The Plan denied
your request. The Plan says that no clinical records documenting an evaluation by the treating physician after
January 4, 2021 were provided.

The Plan follows Medicare rules. Medicare rules say that continued TTFT is covered if the above criteria is
met.

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 continued TTFT. Our reviewer says
that continued TTFT is not medically reasonable and necessary for the enrollee. This patient was last seen 13
days after starting Optune and there is no documentation afterward of an on-person clinical re-evaluation by the
treating practitioner or objective evidence of adherence to therapy, reviewed by the treating practitioner. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued TTFT.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued TTFT have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued tumor treatment field therapy (TTFT) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and treatment of root canal obstruction (D3331) provided on August 25, 2020.

You asked the Plan to pay for the preventive procedure and treatment of root canal obstruction. You say that you have already paid your out of pocket share for the procedure. The Plan denied your request. The Plan says these services are not covered.

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 pay for the preventive procedure (D1999) and treatment of root canal obstruction (D3331) provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the walker purchased on August 24, 2020.

You asked the Plan to reimburse you for the wheeled folding walker. You say that walkers are a covered item. The Plan denied your request. The Plan says to receive payment for covered Medicare items a provider or supplier must be enrolled in the Medicare program.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. 

The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the walker purchased on August 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you are a fall risk. The Plan denied your request. The Plan says the admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you are medically stable. You have no skilled nursing needs. You have been receiving skilled rehabilitation services in the hospital, but the records do not show that you require skilled therapy services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.