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

We decided that the Plan does not have to pre-approveComputed Tomography Colonography (CTC) (74263).You asked the Plan to pre-approvethe Colonography. You say that the CT Colonography is medically necessary.The Plan denied your request. The Plan says the requested screening test is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that Computed Tomography Colonography is not a covered colorectal cancer screening test. We looked at the file and Medicare rules. CTC is not a covered benefit. The records do not detail why traditional methods are not suitable. Based on this information, we decided that Medicare rules for coverage of the Colonography have not been met.Therefore, we decided that the Plan does not have to pre-approveComputed Tomography Colonography (CTC) (74263).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient rehabilitation care provided December 6, 2019 to December 11, 2019.You asked the Plan to waive the copayment. You say that your understanding is that you should have received twenty-onedays of rehabilitation without a copayment being charged.The Plan denied your request. The Plan says the cost sharing has been applied correctly to the inpatient rehabilitationcare provided.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 paya $150 copayment per day, for days 1-5foreach medically necessary covered inpatient stay. You have been asked to pay a $750 copayment($150 x 5 days)for the inpatient rehabilitation careprovided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copaymentfor the inpatient rehabilitation care provided December 6, 2019 to December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 2, 2019.
You asked the Plan to pay for the testing services. You say that the provider needs to know if the enrollee is taking substances which can interaction with prescribed medications. The Plan denied your request. The Plan says the documentation does not itemize what tests are included in the panel.
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 G0481 is definitive drug testing of 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. There are insufficient medical records that shows the testing was individualized to identify 8-14 specific non-prescribed medications or illicit substances. The records do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transthoracic echocardiogram (TTE).You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has intermittent palpitations but no documented dysrhythmias, no exertional symptoms concerning for coronary ischemia or congestive heart failure, and no evidence of structural or valvular heart disease on physical exam. Current guidelines endorsed by several national organizations do not consider TTE appropriate in this setting. The records do not support that the TTE is 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-approvea transthoracic echocardiogram (TTE).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit provided on August 30, 2019.You asked the Plan to pay forthe home visit. 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 the home visit. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided, the home visit on August 30, 2019, was not medically reasonable and necessary for the enrollee in this case, as the provider of the service was not a physician or qualified non-physician practitioner. 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 home visit have not been met.Therefore, we decided that the Plan does not have to pay forthe home visit provided on August 30, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebone marrow aspiration for bone grafting for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvebone marrow aspiration for bone grafting for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a canthoplasty billed with CPT code 67950-RT for date of
service December 19, 2019.
You asked the Plan to pay for the canthoplasty. You say that the medical records provided support payment for
the canthoplasty services in dispute. The Plan denied your request. The Plan says the operative report did not
include documentation of a canthoplasty, and the code cannot be verified.
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 67950-RT is canthoplasty (reconstruction of canthus.)
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 canthoplasty. Our reviewer says that the
records do not support that the CPT code billed was provided on the date of service in dispute. Our physician
reviewer found the enrollee has a diagnosis of Malignant neoplasm of head, face and neck. She presented for
reconstruction of the brow after MOHS surgical removal of a melanoma in situ of the right brow. The records
provided show that the procedures performed were a cheek rotation flap, a right pedicled brow lift, a right skin
graft of the forehead, and an advancement flap of the right upper eyelid.
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 canthoplasty have not been met. Therefore, we decided that the Plan does
not have to pay for a canthoplasty billed with CPT code 67950-RT for date of service December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forscreening infectious agent testing provided on February 6, 2020.You asked the Plan to pay forinfectious agent testing. You say that these tests are covered for the diagnosis code billed.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not a Medicare benefit for the diagnosis listed and were performed for screening purposes.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 rules say that screening for sexually transmitted infections (STIs) is only covered for beneficiaries who meet certain criteria.The test at issue in this appeal, infectious agent testing, was requested solely for screening purposes.The documentation submitted does not show that the beneficiary met any of the covered indications for this testing.Medicare does not cover this test solely for screening purposesexcept for specific beneficiaries.Therefore, we decided that the Plan does not have to pay forscreening infectious agent testing provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided on January 17, 2020.
You asked the Plan to pay for the eyewear. You say that you were unaware that the 2 year time period had to
be to the day. The Plan denied your request. The Plan says that the claim processed correctly.
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 says that you have a vision allowance every two years for routine eyewear..
We looked at the file and the Plan's rules. The file indicates you previously used your routine eyewear
allowance on January 26, 2018, which is less than two years before this date of service. Based on this
information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we
decided that the Plan does not have to pay for the eyewear provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean American Flag attachment for a power wheelchair.You asked the Plan to pre-approvethe American Flag attachment. You say that the documentation provided supports the need for the item in dispute.The Plan denied your request. The Plan says the American Flag does not serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvean American Flag attachment for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSupartz FX for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medicallynecessary.The Plandenied your request. The Plansaysthe requested viscosupplementalagent for treating osteoarthritis pain of the knee is subject to step therapy.Medicare covers Part B medications when they are reasonable and necessarybut 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the required drugs -Orthovisc and Monovisc. There is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approve Supartz FX for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forcustodial care, shoe extensions, wheelchair ramp, routine transportation, commode, dressings, over the counter drugs, and grab bars.You asked the Plan to reimburse you forcustodial care, shoe extensions, wheelchair ramp, routine transportation and grab bars. You say that these items were medically necessary.The Plandenied your request. The Plan says you did not have physician ordersand some items are statutorily not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.You do not have a supplemental benefit for over the counter itemsor routine transportation.Wheelchair ramps, custodial care, and grab bars are not covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you forcustodial care, shoe extensions, wheelchair ramp, routine transportation, commode, dressings, over the counter drugs, and grab bars.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethe referral. You say that you have been advised to not go out of the house for care due to the current public health emergency. The Plan denied your request. The Plan says there are providers available in-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider withthe 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-approvea referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehydroxychloroquine sulfate.You asked the Plan to pre-approvethese services. You say that you disagreewith the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approvehydroxychloroquine sulfate.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded 80307 and G0483 provided on May 10, 2019.You asked the Plan to pay forthe 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.We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition form or medical records stating exactly what tests were to be performed. 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 forthe drug testing coded 80307 and G0483 provided on May 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on December 6, 2019.
You asked the Plan to pay for the complete maxillary denture. You say that the enrollee's denture cracked, and attempts were made to repair the denture, but they continued to crack. You also say that the enrollee was not satisfied with the results of the denture and received a new denture from another provider. The Plan denied your request. The Plan says the maximum allowed for replacement of existing full/partial maxillary dentures has been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, complete denture, immediate denture, or partial denture are limited to one set of dentures every five years. The record shows that the enrollee received an immediate maxillary denture (D5130) on June 21, 2017, and the enrollee's maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the medical eye exam provided on November 18, 2019.
You asked the Plan to waive the copay for the medical eye exam. You say that this was a routine eye exam and should not have a copay. The Plan denied your request. The Plan says that this processed with the correct copay.
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 $40 copay for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $40 copay for the medical eye exam. The medical eye exam falls within the Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye 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 copay for the medical eye exam provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 4, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no medical
record of physician contact.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the testing services ordered following the non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the lab services provided on
July 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and application of desensitizing medicament (D9910) provided on December 30, 2019.You asked the Plan to pay forthe problem focused limited oral evaluation, first intraoral periapical x-ray, and application of desensitizing medicament. You say that the providers never told you the cost of the services before providing them. You also say that you live on a fixed income.The Plan denied your request. The Plan says these services are not covered by the 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 forthe problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and application of desensitizing medicament (D9910) provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation for the sacroiliac joint.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the requested service has not proven to be helpful.The Plan must follow Medicare rules. Medicare rules say that that radiofrequency ablation used for sacro-iliac joint pain is considerednot medically necessary.We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation for the sacroiliac joint.