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

We decided that the Plan does not have to pre-approve in-home blood work to be provided by an out-of-network provider.
You asked the Plan to pre-approve the blood work. The Plan denied your request. The Plan says the services are available 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve in-home blood work to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.

You asked the Plan to pre-approve the requested device. You say that the enrollee has been suffering from lumbar spinal stenosis for many years. The Plan denied your request. The Plan says there is lack of evidence to support the device as 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 the requested device. Our physician reviewer found that the interspinous spacer device remains experimental. More research is needed to show the safety and efficacy of these devices. Therefore, the requested device 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says only two daily insulin injections are required.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are using insulin 70.30 insulin which is usually prescribed two days a day, and is almost never given by a sliding scale where dose adjustments are made based on blood glucose data on a regular or daily basis. The criteria is not met. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unspecified oral surgery procedure (D7999).
You asked the Plan to pre-approve the dental service. You say that you need this service because you are in
pain. You also say that you were referred to an oral surgeon by your dentist. The Plan denied your request. The
Plan says unspecified oral surgery procedure is not listed and therefore is not a 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, 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 an
unspecified oral surgery procedure (D7999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (K0800).

You asked the Plan to pre-approve a power operated vehicle. You say that the requested item is needed for you
to get around. The Plan denied your request. The Plan says the requested item is for use outside the home.

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 case record indicates that 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 Group 1 power operated vehicle (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the COVID-19 testing provided on August 3, 2020.

You asked the Plan to provide reimbursement for the COVID testing. You say that you feel that this should be reimbursed as COVID testing should be covered in full. The Plan denied your request. The Plan says the documentation provided does not clearly show an itemized bill indicating this as a COVID test. There is no valid procedure code or diagnosis code from the provider.

The Plan must follow Medicare rules. Medicare rules say that enrollees or providers, as appropriate, must submit sufficient documentation to support that payment is due. 

In this case, there is not sufficient documentation to support that this charge is payable. There is no information from the provider that identifies this charge as being for a COVID test. Without proper codes and/or records from the provider, it cannot be determined whether Medicare criteria have been met. Therefore, we decided that the Plan does not have to provide reimbursement for the COVID-19 testing provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services rendered on October 9, 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 services were not urgent or emergent and rendered by an out-of-area provider.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.

We looked at the file and Medicare rules. The file shows that the services were not for an unforeseen illness or
injury. 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 telehealth services rendered on October 9,
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from September 5, 2020, to October 12, 2020.
You asked the Plan to waive the copayment for the SNF care. You say that you were told that this stay would be covered in full under your insurance. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $0 copayment per day for days 1 to 20, a $160 copayment per day for days 21 to 51, and a $0 copayment for additional Medicare covered days, up to 100 days for Skilled Nursing Facility (SNF) Care. This SNF stay lasted 37 days, which were days 1 to 37 of the benefit period, resulting in a total copayment amount of $2,720. You have been asked to pay a $0 copayment per day for days 1 to 20, a $160 copayment per day for days 21 to 51, and a $0 copayment for additional Medicare covered days, up to 100 days for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF care provided from September 5, 2020, to October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and management by an out-of-network
provider.

You asked the Plan to pre-approve the evaluation and management. The Plan denied your request. The Plan
says in-network providers are available.

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
evaluation and management by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement transport chair.
You asked the Plan to pre-approve a replacement transport chair. You say that your transport chair was broken, and you threw it out. The Plan denied your request. The Plan says you received a transport chair on April 18, 2017 so the chair is still under reasonable useful lifetime.
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during the reasonable useful lifetime of the equipment. We looked at the file and Medicare rules. The transport chair is under reasonable useful lifetime for 5 years from the day received. There is no information on repairability. Based on this information, we decided that Medicare rules for coverage of a replacement transport chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement transport chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had a contraindication or intolerance to zoledronic acid or has had an osteoporsis related fracture.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia (J0897). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug. There is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. The enrollee does not have a history of an osteoporosis related fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on July 9, 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 there is no documentation for an
electrocardiogram interpretation by the rendering provider being performed as either a component of the
cardioversion service or a separate/distinct service.
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 93010 is electrocardiogram, routine ECG with at least 12
leads; interpretation and report only.
We asked our coder 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 electrocardiogram. Our reviewer says that CPT code
93010 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation
submitted did not include an electrocardiogram interpretation and report, to confirm CPT 93010 was
performed. Modifier 59 cannot be verified as a separate procedure, as no documentation was submitted to
confirm, electrocardiogram was a distinct procedure service.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan
does not have to pay for the electrocardiogram (93010) provided on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).

You asked the Plan to pre-approve the dental service. You say that you have a "balcony" in the upper jaw. You say that without a lower denture, the upper denture does not hold or stick. You say that this makes it difficult to chew. You also say that you would like this to be covered. The Plan denied your request. The Plan says 1 lower denture is covered every 5 calendar years. The Plan also says that the frequency limit has been reached.

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 and partial lower denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for the lower partial denture that you received on June 13, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266), bone graft at time of implant placement (D6104), and sinus augmentation via a vertical approach (D7952).
You asked the Plan to pre-approve the guided tissue regeneration, bone graft, and sinus augmentation. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.
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 a guided tissue regeneration (D4266), bone graft at time of implant placement (D6104), and sinus augmentation via a vertical approach (D7952).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone 10 MG Tablet.
You asked the Plan to pre-approve Prednisone. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Prednisone 10 MG Tablet.
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics purchased from a provider not certified
with Medicare.

You asked the Plan to pay for the foot orthotics. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says this provider is not eligible to receive
payment because they are not certified with Medicare.

The Plan must follow Medicare rules. Medicare rules say that in order for a provider to receive payment for
services furnished to a Medicare enrollee they must be enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the foot orthotics have not been met. Therefore, we decided that the Plan does not have to pay for
the foot orthotics purchased from a provider not certified with Medicare.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease panel provided on July 29, 2020.
You asked the Plan to pay for the cardiovascular disease panel. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says coverage of Comprehensive Genomic Profiling is limited to one bundled test per specimen and precludes the use of any other molecular testing on the specimen.
The Plan follows Medicare rules. The rules explicitly say that specific CPT codes are required to report cardiovascular disease screening. The test at issue in this appeal, the cardiovascular disease panel, was requested solely for screening purposes. Additionally, no medical records were submitted to verify why this test was ordered and if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular disease panel provided on July 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on May 16, 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 the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for these services was not filed until November 12, 2020. A valid Waiver of Liability (WOL) was not received until January 12, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on May 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a powered pressure-reducing air mattress is covered when specific criteria are met. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has no evidence of multiple stage two pressure ulcers located on the trunk or pelvis that have failed to improve over the past month. There is no evidence of large or multiple stage three or four pressure ulcers on the trunk or pelvis, or evidence of a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. The services are not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the surgery services provided on July 31, 2020.

You asked the Plan to waive the copay for the services provided. You say that the provider ruined your ability to perform your occupation. The Plan denied your request. The Plan says the cost share for the services is correct.

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 $250 copay for outpatient surgery. 

You have been asked to pay a $250 copay for the services provided. The services fall within the outpatient surgery benefit category. The copay is not determined by the outcome of the services provided. 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 copay for the surgery services provided on July 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided October 11, 2020 to November 9, 2020.
You asked the Plan to pay for the SNF services. You say that the SNF services were medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary was at a supervision to minimal assist level with functional mobility, including gait to 100 feet with a rolling walker. The beneficiary did not require skilled nursing or therapy services on a daily basis.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided October 11, 2020 to November 9, 2020.