Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and the intraoral periapical x-ray (D0220) received January 19, 2021.
You asked the Plan to pay for the dental services. You say that you had an abscessed tooth that was removed. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
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 limited oral evaluation - problem focused (D0140), and the intraoral periapical x-ray (D0220) received January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for heart rhythm symptom-related transmission and analysis of 24-hour EKG monitoring up to 30 days (CPT code 93271) provided to the enrollee on November 13, 2020, by an out-of-network provider.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 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 heart rhythm symptom-related transmission and analysis of 24-hour EKG monitoring up to 30 days (CPT code 93271) provided to the enrollee on November 13, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the folding walker (CPT code E0135) provided to the enrollee on October 7, 2020, by an out-of-network provider.
You asked the Plan to pay for the folding walker. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network and the services were 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 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 folding walker (CPT code E0135) provided to the enrollee on October 7, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair.
You asked the Plan to pre-approve a recliner chair. You say that you can only sleep in a recliner because a bed
is not good for your health. The Plan denied your request. The Plan says that this is not covered by your plan.
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-approve a recliner chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a wrist-hand orthosis (L3908) provided on February 16, 2021.
You asked the Plan to waive the coinsurance for a wrist-hand orthosis. You say that the requested item was not needed or wanted. The Plan denied your request. The Plan says the correct coinsurance was 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for durable medical equipment, oxygen/oxygen equipment, and related supplies. The enrollee has been asked to pay $12.35, or 20% of the Medicare-allowed amount of $61.78, for a wrist-hand orthosis. A wrist-hand orthosis falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a wrist-hand orthosis (L3908) provided on February 16, 2021.
Your complaint about receiving incomplete or erroneous information from the provider about the enrollee's cost-sharing responsibility is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee has not met step therapy requirements.

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 Prolia. Our reviewer says that the requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of one oral and one intravenous bisphosphonate therapy before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Revatio for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Revatio for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for tumor excision (49205) provided on May 14, 2020.

You asked the Plan to pay for tumor excision. You say that this is docuemented. The Plan denied your request. The Plan says that this code is 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 49205 is excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter. 

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 tumor excision. Our reviewers says that this code is supported. Our physician reviewer found the operative report documents "This was resealed sharply using Bovie electrocautery for complete cytoreduction of tumors Involving the peritoneum measuring greater than 5 cm." 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tumor excision have been met. Therefore, we decided that the Plan has to pay for tumor excision (49205) provided on May 14, 2020.

If the Plan does 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/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 11, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 11, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve abdominal vessels and carotid vertebrobasilar, duplex scan of extracranial arteries, complete bilateral study (93880) and duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study (93925).

You asked the Plan to pre-approve the abdominal vessels and carotid vertebrobasilar.. You say that the medical records provided support the necessity of the services in dispute The Plan denied your request. The Plan says that the requested services are not medically necessary for the enrollee.

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 abdominal vessels and carotid vertebrobasilar.. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has a prior history of CVA with residual weakness. He has a history of cigarette smoking, hypertension and is over 65. Presumably the prior CVA was due to embolic stroke and there is no current or recent information on the status of his carotid arteries. Duplex scanning of the carotid vessels would therefore be medically necessary to assess baseline disease in a high-risk patient. He would meet the medical necessity criteria for a single abdominal duplex ultrasound to assess for an aortic aneurysm based on these risks even in the absence of symptoms or signs. This would therefore meet the medical necessity and reasonableness criteria of the applicable CMS Section 1862(a)1 (A) rule.

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 abdominal vessels and carotid vertebrobasilar. have not been met. Therefore, we decided that the Plan has to pre-approve abdominal vessels and carotid vertebrobasilar, duplex scan of extracranial arteries, complete bilateral study (93880) and duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study (93925).

If the Plan does 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/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve PT services to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 physical therapy (PT) services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from November 29, 2020 to December 5, 2020.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not have to pay this because of an improper procedure.The Plan denied your request. The Plan says that the claim was processed 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 $360 copayment per day, for days 1 to 5 of Inpatient hospital care. 

You have been asked to pay a $1,800 copayment for the inpatient hospital services. The inpatient hospital services fall within the days 1 to 5 of 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 hospital services provided from November 29, 2020 to December 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
February 5, 2021, through February 7, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you went to the emergency room for pain medication and found out you needed to have surgery. You say that you believe the emergency room visit and the surgical procedures were medically necessary. The Plan denied your request. The Plan says upon reconsideration review of the medical records, the appeal request and Medicare criteria the health Plan's Medical Director noted that you had an uncomplicated ambulatory surgery procedure that did not warrant an inpatient admission.
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 pay for 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 that you underwent a laparoscopic cholecystectomy, and you were discharged home on February 7, 2021. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 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 pay for the acute inpatient hospital care provided from February 5, 2021, through February 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthesis (L5301, L5637).

You asked the Plan to pre-approve the replacement prosthesis. You say that the new prosthesis is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. 

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 replacement prosthesis. Our reviewer says that the replacement prosthesis is not medically necessary. Our physician reviewer found the documentation doesn't support that the beneficiary is a K3 ambulator and there is no indication that the prosthesis has not had a new socket to better fit the beneficiary. The requested new advanced prosthesis 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 replacement prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthesis (L5301, L5637).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory viral panel (87631) provided on January 8, 2021.

You asked the Plan to pay for a respiratory viral panel. You say that this was medically necessary. The Plan denied your request. The Plan says the requirements for coverage were not met.

The Plan must follow Medicare rules. Medicare rules say that tests billed with 87631 are covered when billed in places of service 20, 21, or 23 or when ordered by an infectious disease specialist.

We looked at the file and Medicare rules. The testing at issue was billed in place of service 81 and the record does not show it was ordered by an infectious disease specialist. Based on this information, we decided that Medicare rules for coverage of a respiratory viral panel have not been met. Therefore, we decided that the Plan does not have to pay for a respiratory viral panel (87631) provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for drug testing. You say that you are an in-network provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with 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 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 drug testing provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies coded 95910 and the needle electromyography services coded 95886 provided on August 17, 2020.

You asked the Plan to pay for the nerve conduction studies and the needle electromyography services. 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 95910 and 95886 are not supported in the medical record. Specifically, the technical report did not include documentation of nerve conduction studies, for 7-8 studies; therefore, code 95910 cannot be verified. The technical report did not include documentation of a complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed separately in addition to code for primary procedure); therefore, code 95886 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies and the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies coded 95910 and the needle electromyography services coded 95886 provided on August 17, 2020.