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

We decided that the Plan does not have to pay for molecular pathology procedure (CPT code 81404) provided to the enrollee on October 29, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The provider is supposed to supply records prior to the test to show what the treatment plan is and why this testing is necessary as opposed to a screening. Therefore, we decided that the Plan does not have to pay for molecular pathology procedure (CPT code 81404) provided to the enrollee on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral foot inserts.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve bilateral foot inserts.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Left Knee Genicular Nerve Block (64454).

You asked the Plan to pre-approve the nerve block. You say that the nerve block is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was insufficient documentation provided to show that the patient had fully exhausted all conservative options for her knee pain prior to this secondary option. 

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 nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a Left Knee Genicular Nerve Block (64454).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS HF system.

You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says that the requested CardioMEMS HF system is not medically necessary.

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 a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is medically necessary. Our physician reviewer found the enrollee has severe heart failure with preserved EF and severe pulmonary hypertension. She is on multiple congestive heart failure (CHF) medications, a complex diuretic regimen as well as treatment for pulmonary hypertension with recent hospitalization for CHF. Management of her heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping her with minimal symptoms and has resulted in acute hospitalization. Cardiomems device monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens. Data from the Champions trial along with longer term follow-ups studies have shown a significant decrease in hospitalizations and mortality with the use of this device. There is also published expert opinion in the cardiology literature as to its appropriate use, FDA approved indications, as well as reasonable patient selection criteria, all of which are met in this clinical instance. Given the severe symptoms of recurrent CHF, severe pulmonary hypertension, and cardiorenal syndrome, all of which appear very sensitive to volume loading conditions, along with the complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this enrollee, the use of the Cardiomems device is reasonable to more meticulously manage her fluid status and has both clinical data and expert opinion to justify its use in selected appropriate clinical situations. This meets the medical necessity and reasonableness criteria of the applicable CMS Section 1862(a) rule for this clinical situation. 

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 CardioMEMS HF system have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS HF system.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 8, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transtelephonic rhythm strip pacemaker evaluation provided on December 29, 2020 by an out of network provider.

You asked the Plan to pay for transtelephonic rhythm strip pacemaker evaluation (93293). You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were non emergent and 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 service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for transtelephonic rhythm strip pacemaker evaluation provided on December 29, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and lesion destruction provided by an out-of-network provider on September 8, 2020.

You asked the Plan to pay for the office visit and lesion destruction. You say that you were informed the referral was not required when the provider is in-network. You say that the services were medically necessary and the claim should be reprocessed. The Plan denied your request. The Plan says care must be received from a network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit and lesion destruction provided by an out-of-network provider on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteopathic manipulation treatment provided on December 31, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the osteopathic manipulation treatment. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider is out of network and no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 osteopathic manipulation treatment provided on December 31, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 27, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you should only pay a $20 copayment and you would like to be reimbursed. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment for provider and professional services at an in-network specialist's office.

You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty, extra-wide hospital bed (E0301).

You asked the Plan to pre-approve the bed. You say that you have ALS and need this type of bed. The Plan denied your request. The Plan says a semi-electric standard hospital bed was already approved.

The Plan must follow Medicare rules. Medicare rules say that a heavy-duty extra wide hospital bed is covered for enrollees whose weight is more than 350 pounds, but less than 600 pounds.

Your weight is 226 pounds. You do not qualify for this type of bed. Based on this information, we decided that Medicare rules for coverage of the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty, extra-wide hospital bed (E0301).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, including any pins when required (D2950).

You asked the Plan to pre-approve the core buildup. You say that the service is medically necessary. The Plan denied your request. The Plan says code D2950 is not listed under the enrollee's dental benefits and is therefore not a covered 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 pre-approve the core buildup, including any pins when required (D2950).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on December 4, 2020.

You asked the Plan to pay for the services provided. You say that the claim was submitted with the appropriate modifier. The Plan denied your request. The Plan says the service was provided to the enrollee who was incarcerated.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. We find that the claim provided was not billed correctly. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on December 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B medication provided on January 11, 2021.

You asked the Plan to waive the coinsurance for a Part B medication. You say that you were not told there would be a charge for the injection. You say you are on a fixed income and cannot afford a bill this big. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for each Medicare-covered Part B drug. 

You have been asked to pay $113.41 which is 20% of the allowed amount for a Part B medication. The allowed amount is $567.04. ($567.04 x 20% = $113.41). The Part B medication 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 coinsurance for the Part B medication provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care with an out-of-network provider.

You asked the Plan to pre-approve continued care with an out-of-network provider. You say that the requested continued care with an out-of-network provider is medically necessary. The Plan denied your request. The Plan says the requested continued care with an out-of-network provider is not medically necessary.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 

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 continued care with an out-of-network provider. Our reviewer says that the requested continued care with an out-of-network provider is not medically necessary. Our physician reviewer found the enrollee has chronic low back pain, facet and radicular signs and symptoms. She is taking Gabapentin and Oxycodone for pain. She has been seeing an OON provider. The Health Plan has 3 Pain Management physicians available to see her. There is nothing unique or difficult in this enrollee's management that requires her going OON. The request 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 continued care with an out-of-network provider have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care with an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria have not been met.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 32 one-way transportation trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230 x 2) provided on December 8, 2020.

You asked the Plan to pay for the periapical x-rays. You say that you went to the dentist that you always go to. You say that the office was sold and now they are out of network. You also say that you thought your plan covered up to $1,000. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network are not covered. The Plan also says that periapical x-rays are not listed as covered services.

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, dental services that you receive out of network are not covered. Additionally, periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230 x 2) provided on December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on January 13, 2021.

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 70480 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 70480 and 70450. Code 70480 is a column II code with a modifier indicator of 1 when billed with column I code 70450. Code 70480 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on September 28, 2020.

You asked the Plan to pay for the office visit. You say that you attached a referral from the patient's primary doctor and the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was required but not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit provided by an out-of-network provider on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator.

You asked the Plan to pre-approve the requested device. You say that the enrollee is likely to obtain significant therapeutic benefit. The Plan denied your request. The Plan says the device is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation of auricular acupuncture points are non-covered. 

We looked at the file and Medicare rules. The requested device is not covered under any indication. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor or an interstitial continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor or an interstitial continuous glucose monitor. You say that with a continuous glucose monitor you are able to control your sugar levels and not poke your fingers. The Plan denied your request. The Plan says a non-therapeutic blood glucose monitor is not covered by Medicare and you do not meet guidelines for a therapeutic monitor.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. The physician ordered continuous glucose monitoring system, coded A9278, A9276, and A9277 is considered to be a non-therapeutic CGM device per Medicare guidelines and is therefore non-covered. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor or an interstitial continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor or an interstitial continuous glucose monitor.