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

We decided that the Plan does not have to pre-approve radiofrequency ablation, of the nerves innervating the sacroiliac joint (64625).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that this service is considered experimental/investigational due to the wide variation in efficacy in the peer-reviewed literature. Therefore, this request is considered not medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, of the nerves innervating the sacroiliac joint (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dermatology visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the dermatology visit. You say that you need to see a provider who is a cancer specialist. The Plan denied your request. The Plan says the provider is 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 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 the dermatology visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 9, 2020.

You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment. You say you should have been scheduled with the doctor. The Plan denied your request. The Plan says you have been asked to pay 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 $35 copayment for each specialist visit. 

You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the specialist office visit provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, the adult wipes (E1399).

You asked the Plan to pre-approve the adult wipes. You say that you live in a travel trailer, and sometimes you can't get to the bathroom and you need to make sure you're neat. The Plan denied your request. The Plan says this item is not covered.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, the adult wipes (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Durolane (J7318).

You asked the Plan to pre-approve Durolane. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules have not been met because the preferred drugs have not been trialed.

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 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 Durolane. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the enrollee has bilateral knee osteoarthritis. The enrollee is taking Tylenol and Gabapentin. There is no documentation of physical therapy, intra-articular steroid or a nonsteroidal anti-inflammatory drug (NSAID) trial. There has not been a trial of either Monovisc or Orthovisc. The enrollee has not tried the first medication in step therapy and there is no documented contra-indication to either preferred agent.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections (64635, 64636).

You asked the Plan to pre-approve these services. You say that paravertebral facet joint injections are medically necessary. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale.

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 requested services are not medically necessary. Our physician reviewer found that you have chronic low back pain. You are taking non-steroidal anti-inflammatory drugs and ice for pain. You had radiofrequency ablation of the lumbar medial branches on December 17, 2020. The record documents 80% pain relief for three months. Your request is to repeat the radiofrequency ablation. Medicare criteria requires at least 50% pain relief following radiofrequency ablation for six months. The duration of pain relief does not meet the criteria for coverage and therefore, the request is considered not medically necessary or reasonable.

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 paravertebral facet joint injections (64635, 64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided October 7, 2020.

You asked the Plan to pay for the fixed partial denture sectioning. You say that the service should be covered. The Plan denied your request. The Plan says this service is not covered under your dental benefits.

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 fixed partial denture sectioning (D9120) provided October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services coded 37229, 37233, and 37253 provided on May 20, 2020.

You asked the Plan to pay for the surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 codes 37229, 37233, and 37253 are not supported in the medical record. Specifically, the medical records submitted did not include documentation of an open or percutaneous endovascular revascularization, of unilateral tibial or peroneal artery, for the initial vessel, with atherectomy, including angioplasty within the same vessel, when performed.

The medical records did not include documentation of intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation, foreach additional noncoronary vessel (listed separately in addition to code for primary procedure).

The medical records did not include documentation of an open or percutaneous endovascular revascularization, of unilateral tibial/peroneal artery, for each additional vessel, with atherectomy, including angioplasty within the same vessel, when performed (listed separately in addition to code for primary procedure).

An operative report was not submitted with the medical records. Based on this information, we decided that Medicare rules for coverage of the surgery services have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services coded 37229, 37233, and 37253 provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99204) screening pap smear (Q0091) provided on December 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that authorization was impossible due to the enrollee misleading you with incorrect insurance information. The doctor is not responsible to request authorization for a Medicare patient to whom he renders services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99204) screening pap smear (Q0091) provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869).

You asked the Plan to pre-approve the Vertiflex device. You say that this treatment is medically necessary and appropriate for this stage of the disease progression. The Plan denied your request. The Plan says Vertiflex is investigational and experimental and the enrollee is not receiving this device as part of a Medicare covered clinical trial.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2020 to September 29, 2020.

You asked the Plan to pay for home health services. 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. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was billed with an invalid type of bill. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2020 to September 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for positron emission tomography (PET) imaging, skull base to mid-thigh (78812) provided August 4, 2020.

You asked the Plan to pay for the PET scan. You say that please review the attached medical documentation to support the level of service and reprocess your charges for payment to your provider. The Plan denied your request. The Plan says the records do not support the service 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 78812 is positron emission tomography (PET) imaging, skull base to mid-thigh. 

We find that CPT code 78812 is not supported in the medical record. Specifically, the documentation submitted indicates that the service was performed on 08/05/2020. The plan made multiple attempts to obtain the additional information from the provider. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET) imaging, skull base to mid-thigh (78812) provided August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided from October 17, 2020, to October 18, 2020.

You asked the Plan to pay for critical care services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on this service is not documented in the records. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided from October 17, 2020, to October 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534 and the compression stockings identified with code A6531.

You asked the Plan to pre-approve the compression stockings. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.

Although compression stockings described by code A6534 may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. In addition, regarding compression stockings described by code A6531 the record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which these compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534 and compression stockings identified with code A6531.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on June 29, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 

We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the continuous ECG recording provided on September 8, 2020.

You asked the Plan to waive the copayment for the continuous ECG recording. You say that the ECG hookup was not provided so this service date was unnecessary. The Plan denied your request. The Plan says the copayment 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 $20 copayment for diagnostic tests by a specialty physician. 

You have been asked to pay a $20 copayment for the continuous ECG recording. The continuous ECG recording falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the service was 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 copayment for the continuous ECG recording provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses received on March 1, 2021.

You asked the Plan to pay an additional amount for eyeglasses. You say that you do not understand why the Plan will not pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says The Plan says the benefits were applied correctly. The benefit allowance of $100 was applied to the purchase.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $100 allowance per calendar year. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $100 and are therefore, responsible for paying the remainder. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses received on March 1, 2021.