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

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 25, 2020.

You asked the Plan to pay for the orthosis. You say that this was medically necessary for the enrollee.The Plan denied your request. The Plan says that the documentation submitted did not include a valid physician order or an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.

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 proof of delivery and delivery ticket submitted do not have the same date of delivery. 

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 lumbar sacral orthosis provided to the enrollee on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Duplex scan of lower extremity arteries or arterial bypass grafts (93926) provided January 5, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that this should be included in the $45 copayment. You have never been charged this in the past.The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $20 copayment for Medicare covered outpatient diagnostic procedures or tests. 

You have been asked to pay $20 copayment for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and 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 Duplex scan of lower extremity arteries or arterial bypass grafts (93926) provided January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the revefenacin inhalation solution coded J7677 provided from September 28, 2020 to October 1, 2020.
You asked the Plan to pay for the revefenacin inhalation solution. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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, the CPT Code Manual definition of code J7677 is Revefenacin inhalation solution, fda-approved final product, non-compounded, administered through dme, 1 microgram. We find that CPT code J7677 is not supported in the medical record. Specifically, this code has a status code of "M" for a service not billable to the MAC and all remaining lines were denied with reason 0992 please correct OCE edit error on other claim line; therefore, we find the Medicare rule for payment of this September 29, 2020 through October 01, 2020. Based on this information, we decided that Medicare rules for coverage of the revefenacin inhalation solution have not been met. Therefore, we decided that the Plan does not have to pay for the revefenacin inhalation solution coded J7677 provided from September 28, 2020 to October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2750), a prefabricated post and core in addition to a crown (D2954), and endodontic therapy (D3330) provided on May 14, 2020.
You asked the Plan to pay for a crown, a prefabricated post and core in addition to a crown, and endodontic therapy. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a crown (D2750), a prefabricated post and core in addition to a crown (D2954), and endodontic therapy (D3330) provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for unattended electrical stimulation therapy provided from July 28, 2020, to August 25, 2020.
You asked the Plan to pay for electrical stimulation therapy. You say that you were advised that the Plan was authorizing all treatments to their enrollees during the pandemic. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this service is not covered by Medicare or the Plan when performed by a chiropractor.
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 Plan also covers certain routine chiropractic services as a supplemental benefit. For that reason, the Plan's rules apply to this case. The records show that the service at issue is not manual manipulation of the spine. Furthermore, unattended electrical stimulation therapy is excluded from the Plan's supplemental chiropractic benefits. Therefore, we decided that the Plan does not have to pay for unattended electrical stimulation therapy provided from July 28, 2020, to August 25, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee out of network on August 12, 2020.
You asked the Plan to pay for out of network providers. 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 or for outpatient mental health care which is required both in and 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 Plan contract also states outpatient mental health care may require prior authorization both in and out of network. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. 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 outpatient mental health care provided to the enrollee out of network on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on June 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. 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 lab work provided on June 25, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling provided to the enrollee on November 27, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for lung cancer.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Guardant360 molecular pathology genomic profiling provided to the enrollee on November 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided to the enrollee from May 12, 2020 to June 1, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary post-surgery.The Plan denied your request. The Plan says that this is not covered by Medicare.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.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.

Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided to the enrollee from May 12, 2020 to June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bridge for teeth # 6, 7, 8, 9, 10, and 11.
You asked the Plan to pre-approve the bridge. You say that a dental assistant broke your tooth last August. You also say that you need bridge work done as a result. The Plan denied your request. The Plan says the requested bridge is beyond the scope of the policy benefit coverage.
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. The Plan covers the bridge when the services are medically necessary and reasonable. 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 bridge. Our reviewer says that the bridge is not medically necessary. Our physician reviewer found the reviewer found that there are no missing teeth in the upper arch segment that is being requested. Given there are no missing teeth to be replaced in the anterior segment, the reviewer found that the Plan criteria does not provide for the requested treatment and the criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a bridge for teeth # 6, 7, 8, 9, 10, and 11.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 31, 2020.
You asked the Plan to pay for the ambulance services. You say that your wife was following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 31, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on January 26, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crowns (D2740) for tooth #'s 13 and 14.

You asked the Plan to pre-approve the crowns. You say that you need these crowns to be approved for coverage. The Plan denied your request. The Plan says that the x-rays provided do not show that a crown is needed to fix your tooth.

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. The Plan covers the crowns when the services are medically necessary and reasonable.

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 crowns. Our reviewer says that the crown restorations are medically reasonable and necessary. Our physician reviewer found your dental record and radiographs indicate the presence of large restorations in tooth #'s 13 and 14. Our reviewer found that there is documentation indicating pain with biting pressure which may indicate a cracked tooth. Our physician reviewer also found that crown restorations are medically reasonable and necessary to preserve these teeth and to provide adequate masticatory function.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have been met. Therefore, we decided that the Plan has to pre-approve crowns (D2740) for tooth #'s 13 and 14.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).

You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the approved power options come with their own switches.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is necessary for one or more of the additional functions listed in the LCD. 

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 an expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found your strength and function in the upper extremities supports that the patient can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of the LINX Reflux Management System.
You asked the Plan to pre-approve the removal of the LINX Reflux Management System. You say that the enrollee is in pain and needs this device removed. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage is not available for LINX Reflux Management System. We looked at the file and Medicare rules. In this case, because coverage is not available for the LINX Reflux Management System, the subsequent removal of the device will also not be covered. Based on this information, we decided that Medicare rules for coverage of the removal of the LINX Reflux Management System have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of the LINX Reflux Management System.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a CTA scan of the chest (71275) performed on October 22, 2020.
You asked the Plan to pay for a chest CTA. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that inpatient hospital services do not include certain types of services, specified in the Medicare rules section. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CTA of the chest have been met. Specifically, the provider billed Current Procedural Terminology (CPT) code 71275 with modifier 26 indicating that this represents a physician service. Physician services are not included in the Diagnosis-Related Group (DRG) payment to the facility. Therefore, we decided that the Plan has to pay for a CTA scan of the chest (71275) performed on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with supporting records. 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 an office visit provided on November 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies provided on November 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for medical supplies. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these supplies 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 medical supplies provided on November 24, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on January 4, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you would like these services to be covered because you are not comfortable going to a different provider. The Plan denied your request. The Plan says the services were rendered by a provider who is not under contract with the health 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on January 4, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) provided on November 11, 2020, by an out of network provider.

You asked the Plan to pay for a defibrillator. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 automatic external defibrillator (K0606) provided on November 11, 2020, by an out of network provider.