Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue Test Strips (CPT code A4253), for the enrollee.

You asked the Plan to pre-approve the test strips. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says these strips are not on the preferred brand list.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at review, the file, and Medicare rules. These strips are not on the preferred brand list for test strips by the Plan. The Plan made multiple attempts to obtain clinicals that would explain why test strips from the preferred brand list could not be used. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra Blue Test Strips (CPT code A4253), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling provided to the enrollee on March 12, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this should be reported with CPT 81479.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 for Guardant360 molecular pathology genomic profiling provided to the enrollee on March 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90837) received on December 8, 2020.
You asked the Plan to pay for psychotherapy services. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met.
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. Specifically, the Plan has failed to substantiate what necessary criteria the provider has not met. We found that the provider is licensed in the state where the services were performed and is certified by Medicare. There is no compelling evidence why the provider should not receive payment for the services rendered. Therefore, we decided that the Plan has to pay for the psychotherapy services (90837) received on December 8, 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 lette
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on January 22, 2021 by an out of network (OON) provider.

You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for this durable medical equipment.

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 durable medical equipment provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered experimental and investigational.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical
condition as discussed above. FDA indications include implantation of the Superion device at one or two
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no
more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA
indicated levels of "moderate" spinal stenosis (including the planned level of implantation at L4-5).
FDA contraindications include scoliosis and osteoporosis, and have not been adequately addressed in the
medical records. There is imaging evidence of moderate levocurvature of the lumbar spine, and without
documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the
lack of significant osteoporosis in this patient. Plausible other sources of "widespread" pain generation include
complex regional pain syndrome. There is no compelling rationale presented or extenuating circumstances
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for
Vertiflex Superion interspinous device at L4-5 is not medically reasonable or 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair provided on December 8, 2020.
You asked the Plan to pay for a shower chair. You say that the doctor that order this equipment did not follow ordering procedure. The Plan denied your request. The Plan says this item is not a covered benefit.
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 pay for a shower chair provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal) (D4267 x2) and the bone replacement graft for ridge preservation - per site (D7953 x2) received January 5, 2021.
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that you had an infection that needed to be treated. 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
guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal) (D4267 x2) and the bone replacement graft for ridge preservation - per site (D7953 x2) received January 5, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a CardioMEMS device (93264) provided September 21, 2020 to October 21, 2020.
You asked the Plan to pay for the CardioMEMS device. You say that the device was medically necessary. The Plan denied your request. The Plan says that this service is considered investigational and is non-covered.
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 pay for the CardioMEMS device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the device was implanted based on approved FDA and published trial data indications and it is being monitored in accordance with accepted guidelines for use, the monitoring services would be considered medically reasonable and necessary and would not be considered investigational. 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 CardioMEMS device have been met. Therefore, we decided that the Plan has to pay for a CardioMEMS device (93264) provided September 21, 2020 to October 21, 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 waive the copayment for a diagnostic test and coinsurance for an injection provided by a participating provider on February 12, 2021.
You asked the Plan to waive the copayment for a diagnostic test and coinsurance for an injection. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct charges have 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 $30 copayment for outpatient diagnostic tests/in-network/diagnostic tests and a 20% coinsurance for Medicare Part B prescription drugs/in-network.
You have been asked to pay a $30 copayment for a diagnostic test. You have been asked to pay 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,843.52. The amount you are being asked to pay for the injection is $368.70 ($1,843.52 x 20% = $368.70). The total amount you are being asked to pay is $398.70 ($368.70 + $30 = $398.70). A diagnostic test injection falls within the outpatient diagnostic tests/in-network/diagnostic tests benefit category and an injection falls within the Medicare Part B prescription drugs/in-network 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 a diagnostic test and coinsurance for an injection provided by a participating provider on February 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services provided on January 4, 2021 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 an out-of-network 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 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 chemotherapy services provided on January 4, 2021 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 29, 2020.
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 testing is not covered.
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, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve psychotherapy services. You say that you feel like you are being discriminated against. 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 psychotherapy services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), the protective restoration (D2940) and the intraoral - periapical first radiographic image (D0220) received March 31, 2021.
You asked the Plan to pay for the extraction, protective restoration, and intraoral radiographic image. You say that you had a dental emergency and these services were necessary. 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 extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), the protective restoration (D2940) and the intraoral - periapical first radiographic image (D0220) received March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received February 11, 2021.
You asked the Plan to pay for the extraction. You say that you had a broken tooth and it needed to be extracted. The Plan denied your request. The Plan says the requested service is 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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received February 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided from November 29, 2020, to December 28, 2020.
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says it cannot be determined that the services were medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) provided from November 29, 2020, to December 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).

You asked the Plan to pre-approve Durolane. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.

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 Durolane. Our reviewer says that the requirements for coverage of Durolane have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The records do not show that the enrollee has tried Orthovisc and Monovisc, or that these 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee on July 8, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit when done without documentation of medical indication from the treating provider.
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 the denied CPT codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee on July 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirty-six (36) additional OT visits (CPT code 97165),
for the enrollee.
You asked the Plan to pre-approve additional OT visits. You say that the enrollee has a number of
comorbidities, primarily severe right knee arthritis, that prevented rapid progress during OT sessions. You state
the enrollee's decreased mobility at home made OT sessions harder to complete; additionally, it was harder for
the enrollee to complete home exercises due to the knee mobility issues. The Plan denied your request. The
Plan says the enrollee's daily tasks have improved, and their motion is better and as the enrollee improves less
skilled care is needed.
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 additional OT visits. Our physician
reviewer found based on the available records the enrollee appears to have improved with therapy but is still
limited by pain. Further skilled therapy through the nine (9) additional therapy visits that were approved
certainly appears justified. Additional visits beyond these nine (9) additional visits does not appear to be
justified based on the available records.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional OT visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve thirty-six (36) additional OT visits (CPT code 97165), for the enrollee.