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

We decided that the Plan does not have to waive the co-payments for the magnetic resonance imaging (MRI), of any joint of the lower extremity; without contrast material (73721 x 2) provided on October 19, 2020.

You asked the Plan to waive the co-payments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payments have been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 co-payment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office, or at a free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay $220 ($110 co-payment x 2) for the radiological diagnostic services provided. 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 co-payments for the magnetic resonance imaging (MRI), of any joint of the lower extremity; without contrast material (73721 x 2) provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 molecular panel provided on December 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the Guardant360 molecular panel. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this testing was not urgent, emergent or approved in advance.

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 Guardant360 molecular panel provided on December 12, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12-leads; interpretation and report only (93010) provided October 13, 2020.
You asked the Plan to pay for the electrocardiogram. You say that please review the medical records and process for payment accordingly. The Plan denied your request. The Plan says the service rendered is a duplicate of another service billed by the same provider on the same date of 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 93010-59 is electrocardiogram, routine ECG with at least 12-leads; interpretation and report only. We find that CPT code 93010-59 is not supported in the medical record. Specifically, this is a duplicate claim billed by the same provider for the same date of service. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12-leads; interpretation and report only (93010) provided October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that this request is medically necessary. The Plan denied your request. The Plan says the benefit for inpatient care has been exhausted.

The Plan must follow Medicare rules. Medicare rules say that 90 days of inpatient benefit hospital care are covered each benefit period with 60 lifetime reserve days. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Specially, the inpatient hospital care benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Veltassa packets.

You asked the Plan to pre-approve Veltassa packets. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.

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 Veltassa packets.

Benefits for Veltassa packets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs could continue to be met in the skilled facility or at home with home health services and caregiver assistance if requested.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, HHS, AL, LTC). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) and periodontal maintenance (D4910) provided on December 29, 2020.
You asked the Plan to pay for the fluoride and periodontal maintenance. You say that you think these services were coded incorrectly. The Plan denied your request. The Plan says these services are not covered by your supplemental dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) and periodontal maintenance (D4910) provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy - premolar (first root) (D3421) received January 12, 2021.
You asked the Plan to pay for the apicoectomy. You say that the endodontist strongly recommended this procedure. The Plan denied your request. The Plan says this service is not covered under your supplemental benefit.
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 apicoectomy - premolar (first root) (D3421) received January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary, and you disagree with the denial. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility or home with home health and home physical therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR) We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging (MPI) (78452).
You asked the Plan to pre-approve myocardial perfusion imaging. You say that please appeal the denied prior authorization so that the enrollee may have their stress test. The Plan denied your request. The Plan says that this imaging procedure is not considered to be 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 pre-approve myocardial perfusion imaging. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has a known LAD lesion and is having chest discomfort. The enrollee has an enumerated indication. There is no evidence that there is a limitation on the coverage. The elements of the coverage rule are satisfied. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging (MPI) (78452).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two extractions (D7210) and an unspecified restorative procedure (D2999) provided on November 5, 2020.
You asked the Plan to pay for the dental services. You say that you believed this provider was in-network and no one informed you otherwise. The Plan denied your request. The Plan says this provider is not part of the dental Plan's network. Services received from providers who are not part of this network 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. The Plan does not cover dental care provided out-of-network. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services are not covered under this benefit when they are received outside the dental plan's network. Therefore, we decided that the Plan does not have to pay for two extractions (D7210) and an unspecified restorative procedure (D2999) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared modality provided from October 19, 2020, to
November 16, 2020.

You asked the Plan to pay for application of a modality to 1 or more areas; infrared (97026). You say that
acupuncture is covered by Medicare. The Plan denied your request. The Plan says the use of an infrared
therapy device is non-covered.

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, infrared therapy devices are not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the infrared modality provided from October 19,
2020, to November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (K0899).
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device is designed for outdoor use with a top speed of 10 MPH.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 device. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found your mobility deficit is able to be helped by a walker and manual wheelchair. The requested wheelchair is meant for outdoor use and with a top speed of 10 mph, which exceeds your medical need. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0899).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomic testing provided on December 14, 2020.

You asked the Plan to pay for the pharmacogenomic. You say that you would like reconsideration because this service is often paid by Medicare when medically necessary. The Plan denied your request. The Plan says if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.

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, the pharmacogenomic, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the submitted documentation does not include any medical records to verify why this testing was ordered. There is insufficient information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing provided on December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053, 85025, 80061, 36415) provided on January 27, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 lab services (80053, 85025, 80061, 36415) provided on January 27, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance service, basic life support, emergency transport (A0429) provided on November 26, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the enrollee could have been safely transported by another type of vehicle.

The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health.

We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for the ambulance service, basic life support, emergency transport (A0429) provided on November 26, 2020.

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 for physician services (99350) provided on January 8, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized. There were network providers available.
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 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 physician services (99350) provided on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ,continuation of respiratory assist device, bi-level rental, and nose mask.
You asked the Plan to pre-approve continuation of respiratory assist device (E0471) rental and nose mask. You say that you need a nose mask for your respiratory assist device. The Plan denied your request. The Plan says there is no clinical documentation to show a benefit from usage and there are no compliance reports.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation supporting medical necessity or compliance. Based on this information, we decided that Medicare rules for coverage of continuation of respiratory assist device (E0471) rental and related accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve ,continuation of respiratory assist device, bi-level rental, and nose mask.