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

We decided that the Plan does not have to pre-approve a varicose vein treatment (36471).

You asked the Plan to pre-approve the varicose vein treatment. You say that the treatment is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.

The Plan follows Medicare rules. Medicare rules say that varicose vein treatments are covered when 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 the varicose vein treatment. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found there is evidence of saphenous reflux, albeit considered mild by the provider, the veins are not greater than 4 mm, and there is no evidence of 6 weeks of failure of conservative therapy. 

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 varicose vein treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve a varicose vein treatment (36471).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lidocaine injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence found in the peer-reviewed medical literature supporting the safety or efficacy of Lidocaine infusions and it is reported the patient has undergone multiple infusions in the past without any significant or sustained benefit. These infusions have risks of adverse effects, and currently remain experimental and investigational in the general medical community. 
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 Plan does not have to pre-approve a Lidocaine injection for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0299).

You asked the Plan to pay for the home health services. You say that these services were medically necessary. The Plan denied your request. The Plan says the claim was not filed properly and a corrected claim is needed.

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 G0299 is not supported in the medical record. Specifically, in this case the claim was not submitted using the Medicare approved format (UB-04) and required information was not included. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0299) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for telemedicine visit. You say that authorization should not be needed for telemedicine due to COVID-19. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 15, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no significant improvement with therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and the documentation does not indicate that her functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. There has been caregiver and patient training/education. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee 's current condition or to prevent or slow further deterioration.

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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee has been using insulin multiple times (3 or more) a day. There is no documentation that the current treatment requires frequent adjustment on the basis of testing results. There is no documentation that the enrollee is currently using a blood glucose monitor and performing frequent (four or more times a day) 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmologist services provided on November 5, 2020 by an out of network provider.

You asked the Plan to pay for the ophthalmologist services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the non-urgent services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 the ophthalmologist services provided on November 5, 2020 by an out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01951).

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says Original Medicare is liable for payment for these services.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for anesthesia services (01951).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1940, L2275, L2280, L2330, L2820).

You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says documentation provided does not support the items billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain any itemized shipping or billing receipt to confirm what items were delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthoses (L1940, L2275, L2280, L2330, L2820).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an IUD and Liletta.

You asked the Plan to pre-approve the insertion of an IUD and Liletta. The Plan denied your request. The Plan says these services are not covered under Medicare.

The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary. 

Records show that the requested service is primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an IUD and Liletta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine Sulfate for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Morphine Sulfate for the enrollee.

Benefits for this drug 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) services.

You asked the Plan to pre-approve the additional PT. You say that you were run over by a car and have a lot of problem with your back. This causes severe pain, and you feel that PT is needed to help. The Plan denied your request. The Plan says you have received 16 PT visits for your condition, and you have not made substantial progress toward your goal of reducing back pain. Therefore, more PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional PT. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had extensive therapy for this condition and the documentation does not indicate that her functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has had prior instruction on a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 

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 additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27447).

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says this type of provider is not eligible for payment for surgical assistant services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (27447).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (93294, 93296) provided December 19, 2019.

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 Original Medicare is liable for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services (93294, 93296) provided December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627, E1399).

You asked the Plan to pre-approve the seat lift mechanism. You say that the seat lift is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above 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 the seat lift mechanism. Our reviewer says that the seat lift is not medically necessary. Our physician reviewer found there is no documentation provided indicating that the patient has severe arthritis of the hip or a neuromuscular disease. The records do not show that a seat lift is included in the treating practitioner's course of treatment. 

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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627, E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology (colorectal) screening services coded 81528.

You asked the Plan to pay for the oncology (colorectal) screening services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 81528 is oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result.

We find that CPT code 81528 is not supported in the medical record. Specifically, this code was billed with diagnosis code Z12.11 (encounter for screening for malignant neoplasm of colon). This diagnosis code is inconsistent with the procedure billed. Based on this information, we decided that Medicare rules for coverage of the oncology (colorectal) screening services have not been met. Therefore, we decided that the Plan does not have to pay for the oncology (colorectal) screening services coded 81528.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white glass with high gold content crown for tooth #28 (D2750).

You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says this request exceeds the benefit allowance.

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 crowns once every five years per tooth. 

A crown for tooth #28 was last received less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a white glass with high gold content crown for tooth #28 (D2750).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that the service is considered experimental and investigational.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 

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 the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a surgical injection procedure.

You asked the Plan to waive the copayment for outpatient surgery. You say that you have a limited income and cannot afford this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $75 copayment per day for outpatient surgery at an outpatient hospital.

You have been asked to pay $75 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Hospital 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 a surgical injection procedure.