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

We decided that the Plan has to pay forthe refraction services (92015) provided December 2, 2019.You asked the Planto pay forthe refraction services. You say that you were initially told that you had full coverage and that the denial of the refraction services was a mistake. Now you're being told that refraction is not covered by the plan.The Plan denied your request. The Plan says that this claim processed correctly as Original Medicare does not cover routine eye exam (eye refraction) for eyeglasses/contacts.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 1 routine eye exam and the eye exam includes refraction and dilation with a $75 allowance for in-network providers.We looked at the file and the Plan's rules. The health plan contract covers 1 routine eye exam a year. The eye exam includes refraction and dilation with a $75 allowance. Based on this information, we decided that the Plan's rules for coverage of therefraction services have been met.Therefore, we decided that the Plan has to pay forthe refraction services (92015) provided December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for lymphedema of your arm.The Plan denied your request. The Plan says gradient compression stockings A6549 are non-covered when there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the 600 units of catheters provided on December 6, 2019 coded as A4351.
You asked the Plan to pay for the 600 units of catheters. You say that you feel that this should be paid since the rules allow for 90 day supplies to be provided. The Plan denied your request. The Plan says that only 200 catheters per month are allowed and this order of catheters exceeds 200 since the last date of service on November 14, 2019.
The Plan must follow Medicare rules. Medicare rules say that up to 200 units of A4351 are allowed per month. In this case, 600 catheters were provided over the course of three monthly deliveries on September 18, 2019, October 13, 2019, and November 14, 2019. On December 6, 2019, the enrollee was provided 600 catheters in one single delivery, a 90-day supply. Although the new 90-day supply was delivered earlier than one full month after the last delivery on November 14, 2019, there is no evidence that this is actually being provided in excess of the reasonable limitations described in the LCD. A 90-day supply of catheters was delivered 22 days after the delivery date of the prior 30-day supply, which is in accordance with Medicare frequency allowances. Therefore, we decided that the Plan has to pay for the 600 units of catheters provided on December 6, 2019 coded as A4351.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that the enrollee requires the stockings for lower extremity edema.The Plan denied your request. The Plan says gradient compression stockings A6530 are non-covered when there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing on uterine cancer tumor with a test called "Canis MI Profile."
You asked the Plan to pre-approve genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Caris MI Profile is only covered for certain indications. 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 genetic testing. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Malignant neoplasm of the endometrium (stage IV clear cell endometrial cancer). LCD L35396 states that covered testing for uterine cancer includes AKT1, BRAF, KRAS, MLH1 promoter hypermethylation, MSI by PCR, PIK3CA, PTEN, and TP53. The enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for the requested Caris MI Profile. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing on uterine cancer tumor with a test called "Canis MI Profile."
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on November 8, 2019.
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says diagnostic testing as part of a pre-operative examination, where there is an absence of signs or symptoms indicating a need for the test, is not covered under the Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that the use of diagnostic testing as part of a pre-operative examination, where there is an absence of signs or symptoms indicating a need for the test, is not covered under the Medicare benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Per the LCD, the diagnosis code submitted on this claim does not support medical necessity of this pre-operative testing. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided on November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on November 8, 2019.
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 surgical pathology services provided on November 8, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulatory blood pressure monitoring.
You asked the Plan to pre-approve ambulatory blood pressure monitoring. You say that the ambulatory blood pressure monitoring is necessary to capture the blood pressure correctly. The Plan denied your request. The Plan says the documentation does not show blood pressure measurements from 3 separate visits.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no record of the required blood pressure measurements. Based on this information, we decided that Medicare rules for coverage of ambulatory blood pressure monitoring have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulatory blood pressure monitoring.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a non-network provider.You asked the Plan to pre-approvethese services. You say that there are limited therapy options in your area.The Plan denied your request. The Plan says the services are available from network providers.Medicare rules say that plans can require enrollees to get care from networkproviders. 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. The Plan confirmed that they have providers available that can treat your condition. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to a non-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient therapy provided on August 1, 2019to August 15, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient therapy. You say that you were told that you did not need prior authorization.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that this services can be provided in-network.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 foroutpatient therapy provided on August 1, 2019 to August 15, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 surgical extractions (D7210) to be performed by an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that your teeth are causing you problems. You say that you are not able to chew your food properly. You also say that you had gastric bypass surgery 5 years ago and cannot digest food because he cannot chew the food.The Plan denied your request. The Plan says dental services are only covered when performed by a participating general dentist. The Plan also says that 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.Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed by an oral surgeon are not covered. The Evidence of Coverage clearly states that dental services must be performed by a participating general dentist.Therefore, we decided that the Plan does not have to pre-approve4 surgical extractions (D7210) to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gingival irrigation (D4921) for all 4 quadrants.
You asked the Plan to pre-approve the gingival irrigation. You say that the enrollee has significant bone loss. You also say that the services are necessary in order to keep the enrollee's gums healthy and to restore the gums. The Plan denied your request. The Plan says gingival irrigation is not listed as covered service.
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, gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the gingival irrigation (D4921) for all 4 quadrants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex procedure. You say that according to Medicare guidelines this is a covered procedure if certain criteria is met. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is not enough medical evidence to show that this procedure is safe and effective.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental/investigational at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair lift for your vehicle.
You asked the Plan to pre-approve a wheelchair lift. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair lift for your vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says as the services are not urgent or emergent, they can be provided in the enrollee's network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 14060 provided on September 16, 2019.
You asked the Plan to pay for the adjacent tissue transfer or rearrangement. 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. In this case, the CPT Code Manual definition of code 14060 is adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less. We find that CPT code 14060 is not supported in the medical record. Specifically, the medical records did not include sufficient enough information to meet the guide lines of an adjacent tissue transfer or rearrangement of the eyelids, nose, ears and/or lips; defect 10sq cm or less; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or rearrangement have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 14060 provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services t
You asked the Plan to pre-approve the physician's services. You say that you are a veteran and have never seen
a heart specialist before and it is important for you to stay healthy because you care for your sick wife and
family. The Plan denied your request. The Plan says that the plan requires you to receive care from providers
who are part of your primary care physician's (PCP) specialty network.
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 contract with
the Plan also says that the plan requires the enrollee to receive care from providers who are part of the
enrollee's primary care physician's (PCP) specialty network.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve
physician's services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the CPAP supplies provided on February 4,
2019.
You asked the Plan to waive the cost share for the CPAP supplies. You say that your condition supports the
need for replacement parts. You say that the Plan should pay its portion. 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. Your
contract with the Plan says that your deductible is $275, which applies to all items and services except those
specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will
pay our share for your covered medical services. Out-of-network services are not excluded from the deductible.
Your contract with the Plan says that you must pay 30% for each Medicare-covered item from an out-ofnetwork
provider.
The item or service you asked the Plan to waive the cost share for falls within the "Durable medical equipment
(DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in
the contract that your $275 deductible applies to out-of-network services. This cost sharing is a contractual
obligation that had not been met at the time CPAP supplies were received on February 4, 2019. Therefore,
$194.63 has been applied to meet your deductible.
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 has a progressive neuromuscular condition which makes it difficult for her to walk and go about her functions of daily living. You say that her conditions cause her pain which limits her and impacts her way of life. You stated that the enrollee has had surgery in the past, however you believe that future surgeries can be put off with the introduction of the requested orthotics. You say that the requested orthotics are medically necessary for the enrollee to be able to return to a normal, active lifestyle and to alleviate her pain. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea maxillary partial denture.You asked the Plan to pre-approvethe maxillary partial denture. You say that you need work done on your dentures.The Plan denied your request. The Plan says dental care like this was already processed or completed. The Plan also says that there was no supporting evidence that your current partial denture cannot be serviced or repaired.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, you are limited to 1 complete or partial denture every 5 years. The record shows that you received a maxillary partial denture on December 1, 2016 and your partial denture benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture.