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

We decided that the Plan does not have to pre-approveTheraSkin (Q4121 and 15271).You asked the Plan to pre-approveTheraSkin. You say that this is medically necessary.The Plan denied your request. The Plan says this is experimental.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 TheraSkin. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that TheraSkin is medically reasonable and necessary for the enrollee. There is documentation in the case file that this skin substitute has been used previously for this enrollee, but the documentation does not support that it was beneficial.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TheraSkin have not been met.Therefore, we decided that the Plan does not have to pre-approveTheraSkin (Q4121 and 15271).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa Cap 1gm for the enrollee.
You asked the Plan to pre-approve the cap. You say that this is medically necessary for hypertriglyceridemia. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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 Vascepa Cap 1gm for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on October 29, 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 procedure code 99152 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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of the presence of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status. 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 moderate sedation services rendered on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on May 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you provided the services that were requested by the referring provider. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained 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 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 genetic testing provided on May 17, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee's physician wrote a prescription due to the enrollee's severely disfigured feet. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 19, 2019 by an out of network (OON) provider.
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 the services were rendered by a non-contracted provider without prior authorization.
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 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 medical services provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on November 12, 2019.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that you were not aware of your maximum benefit sum. You also say that you were in pain andsaw a doctor, but they were not able to detect a problem.The Plan denied your request. The Plan says you exceeded your maximum 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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on October 29, 2019 and your annual maximum benefit was then exhausted.Therefore, we decided that thePlan does not have to pay forthe problem focused limited oral evaluation provided on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Myocardial perfusion imaging, tomographic or waive the coinsurance for the regadenoson injection provided on October 29, 2019.
You asked the Plan to waive the copayment for imaging and waive the coinsurance for the injection. You say that you were never told about the cost-sharing. The Plan denied your request. The Plan says that the claim did not deny and 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 $175 copayment for Diagnostic radiology other than CT scans and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $175 copayment for the Myocardial perfusion imaging, tomographic and a 20% coinsurance for the regadenoson injection. The Myocardial perfusion imaging, tomographic falls within the Diagnostic radiology other than CT scans benefit category and the regadenoson injection falls within the Medicare Part B prescription drugs 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 Myocardial perfusion imaging, tomographic and waive the coinsurance for regadenoson injection provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the enzyme injection and collagenase injections provided on December 17, 2019 and the occupational therapy and finger brace provided on December 23, 2019.You asked the Plan to waive the cost share for the enzyme injection, collagenase injections, occupational therapy and finger brace. You say that the procedure was pre-approved by insurance. You say that you believed that meant it would be totally covered.The Plan denied your request. The Plan says the cost share 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 $30 copayment for Medicare-covered visits with an in-network specialist, 20% coinsurance for Medicare-covered Part B chemotherapy and prescription drugs from an in-network provider, a $30 copayment for each Medicare-covered visit for in-network outpatient rehabilitation services and 20% coinsurance for each Medicare-covered item and related supplies from an in-network provider. You have been asked to pay a total of $1,880.51 for the enzyme injection, collagenase injections, occupational therapy and finger brace. The enzyme injection falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The collagenase injections fall within the "Medicare Part B prescription drugs" benefit category. Occupational therapy falls within the "Outpatient rehabilitation services" benefit category. The finger brace falls within the "Durable medical equipment (DME) and related 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 cost share for the enzyme injection and collagenase injections provided on December 17, 2019 and the occupational therapy and finger brace provided on December 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea right shoulder arthroscopy (29826), rotator cuff repair with Regeneten (29827), and biceps tenodesis (29828).You asked the Plan to pre-approvea right shoulder arthroscopy, rotator cuff repair with Regeneten, and biceps tenodesis. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried conservative treatment and the rotator cuff tear has not been confirmed.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 a right shoulder arthroscopy, rotator cuff repair with Regeneten, and biceps tenodesis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.Our physician reviewer found the records do not show that sufficient conservative measures have been taken to treat the enrollee's shoulder pain. The medical necessity of the requested surgery has not been established.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a right shoulder arthroscopy, rotator cuff repair with Regeneten, and biceps tenodesis have not been met.Therefore, we decided that the Plan does not have to pre-approvea right shoulder arthroscopy (29826), rotator cuff repair with Regeneten (29827), and biceps tenodesis (29828).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on April 25, 2019.You asked the Plan to pay forthese 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 forthe drug testing rendered to the enrollee on April 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), 1 additional periapical x-ray (D0230) provided on September 25, 2019.You asked the Plan to pay forthe limited oral evaluation and 1 additional periapical x-ray. You say that the services should be paid for. You also say that you were advised that this provider accepted your plan.The Plan denied your request. The Plan says the limited oral evaluation is not a covered service. The Plan says only 1 dental x-ray is covered per year. The Plan also says that the frequency limit for dental x-rays 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 limited oral evaluation is not among those covered under this benefit. Additionally, the frequency limit for dental x-rays has been exceeded. The record shows that the Plan paid for another dental x-ray that you received on the same date of service.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140), 1 additional periapical x-ray (D0230) provided on September 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveroutine transportationYou asked the Planto pre-approvethe transportation. You say that this is medically necessary.The Plandenied your request. The Plansaysthis service is not covered under the enrollee's benefit package.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the transportation have not been met.Therefore, we decided that the Plandoes not haveto pre-approveroutine transportation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) and a tooth extraction (D7210) with an oral surgeon.
You asked the Plan to pre-approve these services. You say that you are in pain and have an infection; therefore, you have been taking antibiotics to be ready for a tooth extraction. The Plan denied your request. The Plan says that dental services are only covered when they are performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.
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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the Plan supplemental dental contract states that dental services must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation (D9310) and a tooth extraction (D7210) with an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there are no medical issues that require supervision by a rehab physician three times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital with altered mental status due to toxic and metabolic encephalopathy. The enrollee was medically managed, with good response. Now, there is no fever or leukocytosis. The hemodynamics and renal parameters are acceptable. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is at moderate to minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea personal emergency response system.You asked the Plan to pre-approvethe emergency response system. You say that this is medically necessary for you to have as you fall a lot and are prone to head injuries.The Plan denied your request. The Plan says this is a statutorily excluded item.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 considered an emergency communication system and doesnot serve a diagnostic or therapeutic purpose.Therefore, we decided that the Plan does not have to pre-approvea personal emergency response system.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy rendered on September 10,
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 procedure code 45380 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 45380 is colonoscopy, flexible; with biopsy, single or
multiple.
We find that CPT code 45380 is not supported in the medical record. Specifically, there is no documentation
that a flexible colonoscopy with biopsy was performed for the billed date of service. 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 colonoscopy rendered on September 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for arthrocentesis (20610) provided on August 21, 2019 through August 22, 2019.You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the documentation submitted did not include documentation of Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance on the billed date of service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan failed to forward any medical records to substantiate the denial of services.Therefore, we decided that the Plan has to pay for arthrocentesis (20610) provided on August 21, 2019 through August 22, 2019.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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 18, 2019 to August 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the home health services (G0156, G0151 and G0299). You say that there are no other provider's in the member's area that accept their insurance. The Plan denied your request. The Plan says services from non-participating providers are not covered under open access unless pre-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 has network providers available who can provide 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 medical services provided on June 18, 2019 to August 13, 2019 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 Freestyle Libre continuous glucose monitor (CGM).You asked the Plan to pre-approve the CGM. You say that the enrollee needs this due to persistent high blood sugar. He only injects insulin once per day but may soon need to add meal time injections.The Plan denied your request. The Plan says the enrollee does not require the number of insulin injections to allow for coverage.The Plan must follow Medicare rules. Medicare rules say that CGMs may be covered for enrollees who require three or more insulin injections per day with frequent adjustment of the dose based on the blood sugar readings. In this case, the enrollee is only testing once per day at this time. As such, the criteria for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).