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

We decided that the Plan does not have to pay for extraspinal chiropractic treatment provided on November 5, 2020.

You asked the Plan to pay for chiropractic treatment. You say that this treatment was necessary to relieve your pain. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan when performed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic treatment provided on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Febuxostat.

You asked the Plan to pre-approve Febuxostat. You say that the enrollee is stable on Febuxostat. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.

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 Febuxostat.

Benefits for Febuxostat 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the external infusion pump and supplies provided from February 16, 2020, to February 21, 2020.

You asked the Plan to pay for the external infusion pump and supplies. The Plan denied your request. The Plan says this coverage criteria are not met.

The Plan follows Medicare rules. Medicare rules say that an external infusion pump is covered when the coverage criteria of the applicable LCD 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 pay for the external infusion pump and supplies. Our reviewer says that the requested external infusion pump and supplies is not medically reasonable and necessary in this case. Our physician reviewer found that the records do not indicate that the antibiotic is administered over an eight hour or longer infusion, or that a strictly controlled rate to avoid toxicity is required. The criteria of the LCD are not satisfied. 

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 external infusion pump and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the external infusion pump and supplies provided from February 16, 2020, to February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided by a participating provider.

You asked the Plan to waive the copayment for an urgent care visit. You say that you went to have a Covid-19 test. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $45 copayment for urgently needed services.

You have been asked to pay a $45 copayment for an urgent care visit. The correct copayment has been applied to the different services that were provided during an urgent care visit. An urgent care visit falls within the urgently needed 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 an urgent care visit provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from November 2, 2020, through November 24, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided from November 2, 2020, through November 24, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497).

You asked the Plan to pay for advance care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

We find that CPT code 99497 is not supported in the record. Specifically, the documentation submitted does not support that 30 minutes of advance care planning were rendered on the billed date of service.

Based on this information, we decided that Medicare rules for coverage of advance care planning have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning (99497).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. 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 the Vertiflex spacer is experimental. More research is needed to show the safety and efficacy of the device. 

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 the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210).

You asked the Plan to pay for the dental service. You say that you were told that the Dental Plan advised the provider that this service would be covered. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service. The Plan says that up to 4 bitewing x-rays are covered. The Plan says that the complete series x-ray has been paid up to the amount of 4 bitewing x-rays. The Plan also says that you are responsible for the remaining amount.

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 complete series x-ray is not among those covered under this benefit. The record shows that the Plan applied payment for 4 bitewing x-rays to the total for the complete series x-ray. You are responsible for the remaining amount. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eyewear.

You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says this is not a covered benefit.

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 when provided by an in-network provider.

We looked at the file and the Plan's rules. The requested eyewear was provided to you by an out-of-network provider. The Plan does not over out-of-network routine eyewear. Therefore, we decided that the Plan does not have to pay for the routine eyewear.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the cone beam CT capture and interpretation (D0364), and the retreatment of a previous root canal (D3348).

You asked the Plan to pay for the limited oral evaluation, cone beam CT, and treatment of a previous root canal. You say that you do not understand why the root canal was not covered. You say that the dentist office advised that the service would be covered. You say that this was the only reason why you went through with the procedure. You also say that you are unable to pay the balance since you are disabled and without a job. The Plan denied your request. The Plan says any dental services that are not listed are not covered. The Plan says retreatment of a previous root canal and cone beam CT capture with interpretation are not listed as covered services. The Plan says that limited oral evaluation is listed as a covered service and it limited to 1 per plan year. The Plan says that the frequency limit has been exceeded.

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 retreatment of a previous root canal and cone beam CT capture and interpretation are not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Additionally, although limited oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the cone beam CT capture and interpretation (D0364), and the retreatment of a previous root canal (D3348).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that you do not want to change providers because this provider is closer to your house. You say that it is hard enough for you to get your medications and you feel more comfortable with this provider. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that these items were medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence that the prescribing physician examined the enrollee.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary for the enrollee. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the positron emission tomography (PET) scan.

You asked the Plan to waive the coinsurance for the PET scan. You say that you were under the impression that this test would not cost this much. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for diagnostic radiology services.

You have been asked to pay 20% coinsurance for the PET scan. The PET scan falls within the diagnostic radiology 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 coinsurance for the positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuro degenerative disease panel provided on September 10, 2020.
You asked the Plan to pay for the neuro degenerative disease panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the neuro degenerative disease panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any medical records to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the neuro degenerative disease panel provided on September 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under code R0070.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim cannot be paid as billed due to issues with incorrect place of service codes and incorrect modifiers billed on the claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to the omission of the appropriate codes required to report the place of service and the units of service. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee and billed under code R0070.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiomyopathy risk testing (81286, 81404, 81407, 81408, 81479) provided on May 15, 2020.

You asked the Plan to pay for cardiomyopathy risk testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of cardiomyopathy risk testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiomyopathy risk testing (81286, 81404, 81407, 81408, 81479) provided on May 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IVIG (Octagam) (CPT code J1568), for the enrollee.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the medication is not necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 medication. Our physician reviewer found Medicare states that for intravenous immunoglobulin (IVIG) to be covered it must have a covered indication as outlined by the Medicare compendia, either FDA approved or off label. There is no documentation of IVIG as a treatment for aplastic anemia. The review has determined that there is no documentation to support that the intravenous immunoglobulin (IVIG) Octagam 500mg is medically reasonable or necessary for the patient. The documentation does not support that the intravenous immunoglobulin (IVIG) Octagam 500mg is safe and effective for the patient.

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve IVIG (Octagam) (CPT code J1568), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules.

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth services provided by a participating provider on November 18, 2020, to December 15, 2020.
You asked the Plan to waive the copayment for telehealth services. You say that you had two phone calls from your doctor. You say that one was to check up on you and one was a pill refill. You say that you do not agree with this high of a copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $45 copayment for outpatient diagnostic tests/specialist. You have been asked to pay a $45 copayment for each telehealth phone call. The total amount you are being asked to pay is $90 ($45 x 2 telehealth calls = $90). The correct copayments have been applied to the services that were provided. Telehealth services fall within the outpatient diagnostic tests/specialist 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 telehealth services provided by a participating provider on November 18, 2020, to December 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal x-ray provided by a mobile provider during a skilled nursing facility (SNF) stay billed with the global code 74018 (professional and technical components).

You asked the Plan to pay for the global imaging service. You say that this was correctly billed and should be paid due to medical necessity. The Plan denied your request. The Plan says the enrollee was in a covered SNF stay on the date of service. As such, only the professional component of the imaging service could be paid separately.

The Plan must follow Medicare rules. Medicare rules say that for enrollees in a Part A SNF stay, separate payment cannot be made for the technical component of imaging services, which is bundled in the SNF Part A payment.

The Plan has attested that this enrollee was in a Part A covered stay. As such, the global fee for this service is not separately payable. Therefore, we decided that the Plan does not have to pay for the abdominal x-ray provided by a mobile provider during a skilled nursing facility (SNF) stay billed with the global code 74018 (professional and technical components).