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

We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.
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 requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental in cases of spinal fusion surgery. More research is needed to show safety and efficacy of bone marrow aspirate. Iliac crest autogenous bone graft remains the gold standard procedure. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 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 bone marrow aspirate for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room.

You asked the Plan to waive the copayment for the emergency room visit. You say that you had to go back to the emergency room because the boot was the wrong size. You say you should not be charged again. 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 $90 copayment for each Medicare-covered emergency room visit worldwide.

You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were evaluated at the emergency room and provided a larger post-op shoe. 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 emergency room.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pathology work provided on October 29, 2020.
You asked the Plan to waive the copayment for the pathology work. You say that you did not request to have the specimen tested and it is not your responsibility to pay the copayment. 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 $20 copayment per day, per provider, for in-network Medicare-covered pathology services. You have been asked to pay a $20 copayment for the pathology work. The pathology work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 pathology work provided on October 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77061).

You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77061 has a status indicator of I and is not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 77061 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77061 has a status indicator of I. This means that CPT code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77061).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on September 24, 2020, and September 25, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you cannot afford to pay for these drugs. The Plan denied your request. The Plan says self-administered drugs are not Part B 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 pay for the self-administered drugs provided on September 24, 2020, and September 25, 2020.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the influenza vaccine (90662) provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the vaccine. You say that this was a medically necessary vaccine and should be covered by the Plan. The Plan denied your request. The Plan says they do not cover out-of-network services except in limited circumstances. The vaccine provided was not urgent or pre-approved.
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 influenza vaccine (90662) provided on November 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 a pneumatic compression device (E0676).

You asked the Plan to pre-approve a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness visit you had on September 21, 2020.
You asked the Plan to pay for the wellness visit. The Plan denied your request. The Plan says the benefit limit has been exhausted.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided on May 21, 2020, less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the wellness visit you had on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit.
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 lumbar-sacral orthosis provided on November 2, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication Retacrit would likely be less effective, and/or cause adverse effects for the member.
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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee. The documentation does not support that Retacrit (Epoetin alfa-epbx) has been tried and failed. The documentation does not support that Retacrit would likely be less effective, and/or would likely cause adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Aranesp. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis. You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show any of the covered problems. 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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no history of recent injury or surgery to the knee and there is no evidence of knee instability documented by exam. The enrollee complained of increased knee pain at the time of the 09/03/2020 evaluation. The enrollee underwent a cortisone injection that provided one week of relief. The 10/15/2020 evaluation noted continued reduction in range of motion with tenderness in the knee. In this case, the examination revealed no evidence of ligament laxity. The 09/03/2020 and 10/15/2020 examinations noted no excessive laxity. The Medicare LCD notes that there must typically be documented instability by examination of the beneficiary and objective description of joint laxity. There was also no recent injury or surgery to the affected knee. There is no evidence of knee instability. Therefore overall, the requested brace is not supported by guidelines in this case. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to the guidelines. Therefore, the requested prefabricated brace is not 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 the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravitreal injection provided on August 18, 2020.
You asked the Plan to waive the copayment for the intravitreal injection. You say that you have been receiving these injections for several years and were never charged an outpatient facility copayment. 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 $350 copayment per visit. You have been asked to pay a $350 copayment for the intravitreal injection. The intravitreal injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 intravitreal injection provided on August 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to preapprove the acute inpatient hospital admission.

You asked the Plan to preapprove acute inpatient hospital care. You say that the inpatient admission post procedure is necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare coverage criteria.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 preapprove acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to preapprove the acute inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary. The Plan denied your request. The Plan says that it was not indicated if the patient had failed a four-week trial of conservative therapy, regular exercise, and elevation of the limb.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met.

Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953), the retainer crowns (D6750 x 2), the pontics (D6240 x 3), and the unspecified preventive service (D1999) provided on October 6, 2020.
You asked the Plan to pay for the dental services. You say that when you got your dental services, they forgot to put the Plan code. You say that you were charged over $4,000. The Plan denied your request. The Plan says bone replacement graft is not listed as a covered service. The Plan says that retainer crowns are not listed as covered services. The Plan says that pontics are not listed as covered services. The Plan also says that the unspecified preventive service is not listed as a covered service.
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 bone replacement graft (D7953), the retainer crowns (D6750 x 2), the pontics (D6240 x 3), and the unspecified preventive service (D1999) provided on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 24, 2020, through September 28, 2020. You asked the Plan to waive the copayment for the inpatient stay. You say that they couldn't perform the procedure, so you were transported to another hospital. You say that you shouldn't have to pay two copayments. 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 $380 copayment per day for days 1 through 5 for covered hospital care. Thereafter, you pay a $0 copayment for additional Medicare-covered days during your hospital admission. You have been asked to pay a $1,520 copayment for the inpatient stay. ($380/day x 4 days = $1,520). The inpatient stay falls within the "Inpatient hospital care" 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 inpatient stay provided from September 24, 2020, through September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint 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 the documentation shows only one of the provocative tests required.

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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a need for two positive SI joint tests in addition to the thigh trust test (Gaenslen's, Patrick's, or Distraction) as well as imaging of the joint with plain x-ray and CT scan or MRI. These have not been documented, therefore, the request is deemed not medically reasonable or necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on May 20, 2020.
You asked the Plan to pay for the IV tubing and infection control supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes S1015 and S8301 have a status indicator of I and are not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes S1015 and S8301 are not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on May 20, 2020.