Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the excision of a parotid tumor or gland (42420) provided on May 30, 2019.
You asked the Plan to pay for the excision of a parotid tumor or gland. You say that this was medically necessary. The Plan denied your request. The Plan says that this was not billed appropriately.
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 42420 is excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve. 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 excision of a parotid tumor or gland. Our reviewer says that this code is supported in the records. Our physician reviewer found the operative report clearly states that a total excision of parotid tumor was performed. The operative report states that the "mass was removed in its entirety." 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 excision of a parotid tumor or gland have been met. Therefore, we decided that the Plan has to pay for the excision of a parotid tumor or gland (42420) provided on May 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses provided to the enrollee on November 1, 2019.You asked the Plan to pay for the orthoses. You say that this should be paid for.The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.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  is "HCPCS L1851:Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated,off-the-shelf HCPCS L2397:Addition to lower extremity orthosis, suspension sleeve"We asked our coding 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 orthoses. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided do not include a copy of an itemized shipping/billing invoice indicating the specific supplies, nor is there a proof of delivery included that meet Medicare criteria for reimbursement consideration.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay for orthoses provided to the enrollee on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve physician's services. The Plan denied your request. The Plan says that members may obtain services from out-of-network providers only when providers of specialized services are not available in the network or in urgent/emergent situations.
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 the requested physician's services. Therefore, we decided that the Plan does not have to pre-approve the physician's services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a monitored home sleep test and breathing capacity test.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 a monitored home sleep test and breathing capacity test are covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the visit note dated March 24, 2020 mentions a history of asthma but does not indicate whether you have active symptoms. There is no context provided for the diagnosis. There is no documentation of sleep-related symptoms or a history of sleep apnea. The records do not support that the requested services are medically necessary at this time. 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 monitored home sleep test and breathing capacity test.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency room (ER) services rendered on July 21, 2019.You asked the Plan to pay for these services. You say that the services were medically necessary.The Plan denied your request. The Plan says that the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee presented to the ER with shortness of breath. The evaluation revealed stable vital signs and the physical exam was notable for crackles in both lung bases, a systolic murmur, and edema in the lower extremities. She was admitted to telemetry. The records support that the ER services are reasonable and 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 been met.Therefore, we decided that the Plan has to pay for the emergency room (ER) services rendered on July 21, 2019.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 pay foracupuncture services (97810 and 97811) provided on January 17, 2020 through February 7, 2020.You asked the Plan to pay forthe acupuncture services. You say that you would like reconsideration because you were referred by your primary care physician.The Plan denied your request. The Plan says acupuncture is not a covered benefit.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 the rules for coverage of the acupuncture services have not been met. Specifically, the recorddoes not indicate that you have a diagnosis of chronic lower back pain.Therefore, we decided that the Plan does not have to pay foracupuncture services (97810 and 97811) provided on January 17, 2020 through February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Gel-One injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe preferred alternatives include: Euflexxa, Durolana, Supartz-FX, and Gelsyn-3.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 reviewerto 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the prescriber states that attempts to obtain Euflexxa failed, and that Gel-One is the only hyaluronan acid product that is stocked in his office. There is insufficient documentation that the plan's step therapy requirements have been met or that the plan's step therapy drugs would not be medically appropriate for this enrollee. In summary, Gel-One is not medically reasonable or necessary at this time.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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Gel-One injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on November 14, 2019.
You asked the Plan to pay for the dental services. You say that you were advised by the office staff that the services you were to receive that day were covered. You say that you were also advised that you were not covered for anything other than preventive dental services. The Plan denied your request. The Plan says services received out of network are not covered. The Plan also says that the provider in this case is not a 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. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that are received out of network are not covered. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on November 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says admission to a SNF is not medically necessary. The Plan says that no daily skilled nursing needs are notes. The Plan says that there is no change in function that needs daily skilled therapy on an inpatient basis only.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care, a need for IV antibiotics or other skilled nursing needs. The enrollee's functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment only in a SNF. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 1, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you should not be responsible for the copayment because your doctor did not order the ultrasound. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $45 copayment for each Medicare-covered x-ray. You have been asked to pay a $45 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received the ultrasound due to a questionable abnormality on the screening images.
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 ultrasound provided on February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9500) provided January 5, 2020
to January 6, 2020.
You asked the Plan to pay for HCPCS code S9500. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says that per the 2020 National Physician
Fee Schedule, HCPCS code S9500 has a status code of I, which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate HCPCS/CPT code. The rules say that HCPCS/CPT codes
with a status indicator of I are not recognized by Medicare and will not be paid. Medicare uses another code for
reporting of, and payment for, these services.
We find that payment for HCPCS code S9500 is not supported. Specifically, S9500 has a status indicator of I
and will not be paid by Medicare. This service should be reported with a code that is recognized by Medicare.
Based on this information, we decided that Medicare rules for coverage of HCPCS code S9500 have not been
met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9500) provided
January 5, 2020 to January 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMyocardial Perfusion Imaging (78451).You asked the Plan to pre-approvethe Myocardial Perfusion Imaging. You say that the service is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.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 Myocardial Perfusion Imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has no documented symptoms that may be anginal, no documented cardiovascular physical exam abnormalities and no documented electrocardiogram. In this circumstance the documentation does not support the medical necessity for nuclear stress testing.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 Myocardial Perfusion Imaging have not been met.Therefore, we decided that the Plan does not have to pre-approveMyocardial Perfusion Imaging (78451).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
Review of the file does not support that the enrollee was prescribed Warfarin. The other laboratory testing at
issue in this appeal 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
provided on January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on October 17, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same items from a different provider that is still within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same orthosis from a different provider on October 17, 2019. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the wrist hand orthosis at issue. In addition, the documentation did not indicate the provider discussed the need for the billed supply code. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on October 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on July 11, 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 services were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee underwent cervical spine surgery. Intraoperative monitoring services were provided during the procedure. The modalities monitored included EEG. The presence of EEG monitoring during cervical spine surgery is not the standard of care. The services were 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 pay for the electroencephalogram (EEG) rendered on July 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has imary osteoarthritis of the right knee and a history of diabetes. The enrollee received an intra-articular injection of Zilretta on November 8, 2019. Per the FDA approved prescribing information, Zilretta is indicated for the management of knee pain due to osteoarthritis and is not intended for repeat administration. It can only be used once per knee per lifetime. The enrollee has already received Zilretta injections; therefore, a repeat injection is not safe and effective 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 Zilretta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from February 4, 2020 to February 11, 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 services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules.Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from February 4, 2020 to February 11, 2020.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.