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

We decided that the Plan does not have to pay for an eye exam with photos (Fundus photography) including interpretation and report (92250) provided on October 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an eye exam with photos (Fundus photography) including interpretation and report. You say that you were told this claim was denied because the provider is not in network for the Plan. You have gone to this provider before and the claim was covered under your plan. You had no way of knowing that this doctor was out-of-network since the claims had been covered in the past. The Plan denied your request. The Plan says 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 we authorize the use of out-of-network providers. The doctor is out-of-network and there was no authorization on file for the service provided.
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 has network providers available who can provide 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 eye exam with photos (Fundus photography) including interpretation and report (92250) provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided to the enrollee on February 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure." We find that CPT code 95999 is not supported in the medical record. Specifically, this code was billed for train of four testing. Train of four testing is not an unlisted procedure. There is a more appropriate code for train of four testing. Additionally, train of four testing is bundled service, and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided to the enrollee on February 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable loop recorder for the enrollee to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no medical need shown as to why the enrollee cannot get this care from a network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an implantable loop recorder for the enrollee to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Superion Interspinous Spacer (22870 and 22869).
You asked the Plan to pay for the Superion Interspinous Spacer. You say that this procedure is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this procedure is experimental.
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 pay for the Superion Interspinous Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental and more research is needed. 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 Superion Interspinous Spacer have not been met. Therefore, we decided that the Plan does not have to pay for a Superion Interspinous Spacer (22870 and 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services (S9328) provided to the enrollee from December 19, 2018 to April 16, 2019.
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. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services (S9328) provided to the enrollee from December 19, 2018 to April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. The Plan denied your request. The Plan says there are providers in your network that can provide the services you need.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve administrative days beginning January 22, 2020.
You asked the Plan to pre-approve the administrative days. You say that the enrollee is homeless and it is not safe to discharge him so you are trying to get him into a group home. The Plan denied your request. The Plan says administrative days are not a covered benefit under Medicare.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the administrative days have not been met. Therefore, we decided that the Plan does not have to pre-approve administrative days beginning January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 9, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular screening provided to the enrollee on October 10, 2019.
You asked the Plan to pay for this service. You say that this testing was medically necessary. The Plan denied your request. The Plan says this testing was done for screening and not related to a specific diagnosis, which is not covered by the Plan or by Medicare.
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, this service, 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 molecular screening provided to the enrollee on October 10, 2019.
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 your foot problems have worsened over the years and you have tried other devices. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF system for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a history of
hypertension, hyperlipidemia, paroxysmal atrial fibrillation, defibrillator placement, coronary disease, stroke
and dilated cardiomyopathy, as well as NYSHA Class III congestive heart failure requiring hospitalization. In
this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated
in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover,
concerns have been raised about potential bias in this trial calling into question the results; therefore, the
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not
recommended in current guidelines for the treatment of heart failure. The procedure is considered
experimental/investigational in nature and is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a CardioMEMs HF system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue Test Strips
You asked the Plan to pre-approve the OneTouch Ultra Blue Test Strips. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says no medical records and/or certificate of medical necessity were provided to show the reason for using this non-preferred strip. The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 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 OneTouch Ultra Blue Test Strips. Our reviewer says that the record does not include an explanation as to why a different test strip and meter would not suffice in this case. Our physician reviewer found the documentation does not clearly state why the member requires OneTouch Ultra Blue Test Strips. 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 OneTouch Ultra Blue Test Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra Blue Test Strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on August 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration based on medical necessity. The Plan denied your request. The Plan says the provider is a non-contracted provider. A review of the enrollee's account does not show a valid referral on file for the dates in question. In addition, the enrollee's services were not urgent or emergent in nature. The Plan does not deny the medical necessity of the services however, the non-contracted provider did not obtain proper authorization and did not follow the rules of the plan.
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 has network providers available who can provide 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 August 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician care.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provided. The Plan denied your request. The Plan says this provider is not in 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve out of network physician care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure.
You asked the Plan to pre-approve Ensure. You say that Ensure is medically necessary. The Plan denied your request. The Plan says oral supplements for nutrition are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. Medicare has specific coverage criteria for enteral nutrition. Based on the medical records you also do not meet the criteria for enteral nutrition. Ensure taken orally is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve Ensure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from April 8, 2019 through May 6, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that the Plan refused to pay for physical therapy. You say that the services should be paid. The Plan denied your request. The Plan says the copayments applied 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 $25 copayment for Medicare-covered physical therapy. You have been asked to pay $150 for physical therapy. ($25/visit x 6 visits = $150). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from April 8, 2019 through May 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction of one tooth (D7140), surgical removal of erupted teeth #6, 11, 12, 13, 15, 21, 22, 27, and 28 (D7210), and alveoloplasty in conjunction with extractions (D7310).
You asked the Plan to pre-approve an extraction of one tooth, surgical removal of erupted teeth #6, 11, 12, 13, 15, 21, 22, 27, and 28, and alveoloplasty in conjunction with extractions. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit or the benefits have been exhausted. Therefore, coverage criteria has not been met.
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 two non-surgical or surgical extractions per calendar year. We looked at this the file and Medicare rules. Specifically, the benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of an extraction of one tooth, surgical removal of erupted teeth #6, 11, 12, 13, 15, 21, 22, 27, and 28, and alveoloplasty in conjunction with extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve an extraction of one tooth (D7140), surgical removal of erupted teeth #6, 11, 12, 13, 15, 21, 22, 27, and 28 (D7210), and alveoloplasty in conjunction with extractions (D7310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an (acute care hospital) having been admitted with a urinary tract infection and renal compromise. The enrollee received antibiotics and was eventually started on hemodialysis. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 10, 2019 and billed under code G0481.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 10, 2019 and billed under code G0481.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) Colonography (74261) provided October 11, 2019.
You asked the Plan to pay for the Colonography. You say that the service should be covered. The Plan denied your request. The Plan says an invalid diagnosis code was used.
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 74261 is not supported in the medical record. Specifically, it is not appropriate to use Z53.8 as a primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the Colonography have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) Colonography (74261) provided October 11, 2019.