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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on October 9, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered to the enrollee on
October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to adjust the payment for Medtronic Quick-Set Paradigm MMT-398
infusion sets provided from April 27, 2018, to July 12, 2019.
The enrollee asked the Plan to adjust the payment for infusion sets for an external insulin pump. The enrollee
said that overpayment of claims should be refunded because the claims were submitted as CPT code A4224
and they should be A4230. The Plan denied the request. The Plan says the coding and coinsurance are correct.
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 A4224 is supplies for maintenance of insulin infusion
catheter.
Based on this information, we decided that the A4224 code is correct and the coinsurance is correct. Therefore,
we decided that the Plan does not have to adjust the payment for Medtronic Quick-Set Paradigm MMT-398
infusion sets provided from April 27, 2018 to July 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transportation tie down and power seat elevation feature for the enrollee.
You asked the Plan to pre-approve a transportation tie down and power seat elevation feature. You say that this equipment is medically necessary in order for the enrollee to safely travel and maintain independence. The Plan denied your request. The Plan says that these devices are not covered by Medicare.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature. The transportation tie down at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. A power seat elevation feature is statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a transportation tie down and power seat elevation feature for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the use of IV medications during a dental procedure.
You asked the Plan to pre-approve the IV medications. You say that this is needed to prevent nausea and reduce swelling. The Plan denied your request. The Plan says this service is not listed as covered in your contract.
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 pre-approve the use of IV medications during a dental procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve a wheelchair. You say that you are requesting an in-network exception. The
Plan denied your request. The Plan says there are in-network providers available for these 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a wheelchair to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not enrolled in a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the records indicate no enrollment in a clinical trial which is a requirement of CMS in this context to qualify for PET scan. The CMS NCD criteria for PET scan in neurocognitive disorders require there to be a differential diagnosis of Alzheimer Disease versus FTD. The requesting neurologist specifically stated there is no clinical sign of FTD. Also, the NCD criteria specify that possible Lewy Body Dementia is not a possible diagnosis for which PET scan will be 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on September 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan saysthe equipment requested is not covered because it is considered equipment without medical necessity.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forultrasound services (CPT 76770) provided to the enrollee on December 3, 2018.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 76770 remains not supported.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 76770 is "ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete."We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records submitted. Our coding reviewer found the medical records provided do not include a "complete" documented evaluation of the abdominal aorta, common iliac artery origins, or the inferior vena cava to corroborate that an ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete was performed on December 3, 2018.We looked at this coder'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 Plan does not have to pay forultrasound services (CPT 76770) provided to the enrollee onDecember 3, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fortesting provided to the enrollee on October 24, 2019 and billed under code83036.You asked the Plan to pay forcode 83036and 76642. You state this claim should be paid. The Plan denied your request. The Plan says while code 76642 will be paid, code 83036 cannot be paid because Medicare guidance says screening tests without a valid medical diagnosis related to the health ofthe enrollee are not a benefit. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Medicare does not cover screening tests. In this case, code 83036 appears to have been ordered as a screening and is not covered by Medicare. Therefore, we decided that the Plan does not have to pay fortesting provided to the enrollee on October 24, 2019 and billed under code83036.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on April 9, 2019.You asked the Plan towaive the copayment forthe ambulance transport. You say that you were informed the transport would be free of charge. You say that you should not have to pay.The Plan denied your request. The Plan says the copayment applied correctly.The rulessay 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 $265 copayment per date of service regardless of the number of trips.You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 forthe ambulance transport provided on April 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided onSeptember 17, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that this claim should be paid because it was not your choice to take the ambulance.The Plan denied your request. The Plan says that you are financially liable for any cost sharing applied, including deductibles, coinsurance and copayments.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 $225 copayment for each separate Medicare-covered ambulance service. You have been asked to pay a $52copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance service benefit category. This means that you have been asked to pay less than 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 forthe ambulance transport provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approveeustachian tube dilation for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis procedure isstill considered experimental and investigational.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found eustachian tube dysfunction, ETD, is a complex problem without a clear standard of care for treatment. Treatments such as PE tube placement create an alternative route for ventilation, but does not address the underlying problem with the ET. The literature does not show evidence of effectiveness of systemic decongestants, antihistamines, nasal topical decongestants, or corticosteroid sprays for ETD. The Academy of Otolaryngology has stated that balloon dilation is appropriate in patients with obstructive ETD who have failed medical therapy for identified treatable causes. PET placement is not a mandatory prerequisite for BDET. The treatment is medically reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have been met.Therefore, we decided that the Planhas to pre-approveeustachian tube dilation for the enrollee.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Privigen 10% vial for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is insufficeint evidence supporting the use of this medication for a diagnosis of small fiber neuropathy.The Plan must follow Medicare rules. The rules say that Medicare paysfor 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 therequest to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation and the compendia do not support that Privigen is medically reasonable and necessary for the enrollee. The documentation and the compendia do not support that this drug is safe and effective 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-approvethe Privigen 10% vial for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe cystourethroscopy provided on October 11, 2018.You asked the Plan to reduce the copayment forthe cystourethroscopy. You say that you had the surgery at an ambulatory surgical center and you should only pay a $100 copayment. The Plan denied yourrequest. The Plan says you have been charged 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 $200 copayment for medical or surgical procedures/treatments received in an outpatient hospital facility, or clinic, including your doctor's office. You have been asked to pay a $200 copayment for the cystourethroscopy. The cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by an outpatient hospital.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 reduce the copaymentforthe cystourethroscopy provided on October 11, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electric scooter.You asked the Plan to pre-approvean electric scooter. You say that you fall and cannot walk and cannot hold your balance.The Plan denied your request. The Plan says you have not had thenecessary evaluations to assure you receive the correct power mobility device.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating therequested PMD. The file does not showthat you have a mobility deficit that impairs your participation in MRADLs, your condition cannotbe improved by a walker, cane or manual wheelchair, or that you cansafely operate the PMD being requested. The physician order does not say what type of scooter is requested. This means that Medicare rules for coverage of a PMD have notbeen met.Therefore, we decided that the Plan does not have to pre-approvean electric scooter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the heart with quantitative evaluation of coronary calcium for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedurecode 75571 is non-covered. We looked at the file and Medicare rules. The requested services are a heart CT with quantitative evaluation of coronary calcium described by code 75571. These services are non-covered by Medicare.Therefore, we decided thatthe Plan does not have to pre-approvea computed tomography (CT) scan of the heart with quantitative evaluation of coronary calcium for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac (SI) joint injections (27096).You asked the Plan to pre-approveSI joint injections. You say that the enrollee had a positive response to previous SI joint injections.The Plan denied your request. The Plan says the records do not show if the enrollee had sufficient improvement from previous injections.The Plan must follow Medicare rules. Medicare rules say that if previous diagnostic or therapeutic SI injections have not effectively relieved the pain, further injections would not be considered medically necessary.We looked at the file and Medicare rules. The submitted medical records do not indicate whether the previous injections effectively relieved the enrollee's pain. Without this information, medical necessity cannot be established. Based on this information, we decided that Medicare rules for coverage of SI joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac (SI) joint injections (27096).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe six core buildups, including any pins when required (D2950).You asked the Plan to pre-approvethe core buildups. You say that due to the amount of tooth loss, you recommend buildups and crowns.The Plan denied your request. The Plan says Medicare does not cover this service and therefore it is not covered by the enrollee's 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 pre-approvethe six core buildups, including any pins when required (D2950).