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

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered benefit.

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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that assessment of cardiovascular risk with multigene variant testing in an elderly patient already on therapy for risk reduction is not clinically indicated or appropriate. This will have no effect on clinical management which should be based on standard clinical laboratory measurements based on AHA/ACC published guidelines. In addition, this therapy has already been instituted in this enrollee, as she is on both statin and blood pressure management therapy, and she should be treated to published guideline goals. Further refinement of risk with a genetic cardiovascular risk assessment panel is not medically necessary in this situation and does not meet CMS rules for coverage.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair repairs.

You asked the Plan to pre-approve wheelchair repairs. You say that you need your wheelchair repaired. The Plan denied your request. The Plan says they will approve a high strength, lightweight wheelchair (K0004) but there is no current physician order or established medical necessity for the accessories.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that you need a wheelchair that is more durable. This means that wheelchair repairs are not necessary. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions.

You asked the Plan to pre-approve the dental extractions. You say that the services being requested are
medically necessary. You say that the dental crown is broken and there is little tooth left. You say that you
need the little tooth left in the gum to be extracted. The Plan denied your request. The Plan says the requested
provided has been identified as an opt out provider and would not be eligible for payment of dental care.

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 coverage is limited to services
provided by dental providers who have not opted out of Medicare. The records show that the provider who you
requested to get the dental extractions from has opted out of Medicare. Therefore, we decided that the Plan
does not have to pre-approve dental extractions.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.

You asked the Plan to pre-approve bone marrow aspiration. You say that the requested bone marrow aspiration is medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspiration is not medically necessary.

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 bone marrow aspiration. Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the enrollee was approved for the requested L4-5 laminectomy and TLIF and the inpatient admission. Bone marrow aspirate remains experimental. More research is needed to show safety and efficacy. Iliac crest bone graft is the gold standard graft material. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on April 13, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that no authorization was required for this service. You have attached the referral from the enrollee's PCP to review for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99215) provided on April 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tangential biopsy of skin services coded 11103 provided on October 6, 2020.

You asked the Plan to pay for the tangential biopsy of skin services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate.

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 CPT code 11103 is not supported in the medical record. Specifically, the documentation supports that this is a duplicate claim to a claim billed by the same provider for the same date of service. Based on this information, we decided that Medicare rules for coverage of the tangential biopsy of skin services have not been met. Therefore, we decided that the Plan does not have to pay for the tangential biopsy of skin services coded 11103 provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair for a seat lift (A9270).

You asked the Plan to pre-approve a recliner chair for a seat lift. You say that you need this item because your current chair does not function properly. The Plan denied your request. The Plan says only the seat lift mechanism is covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve a recliner chair for a seat lift (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next blood glucose test strips.

You asked the Plan to pre-approve Contour Next test strips. You say that the Plan's preferred product requires you to purchase a non-covered computer accessory while Contour Next test strips have a free tool in place to manage your diabetes. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. Medicare rules say that Plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 

We looked at the file and Medicare rules. The Plan limits coverage for blood glucose test strips to Abbott Diabetes Care brand test strips. Based on this information, we decided that Medicare rules for coverage of Contour Next test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next blood glucose test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (cgm) supplies provided on December 7, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor (cgm) supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (cgm) supplies provided on December 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a surgical laparoscopy with a total hysterectomy (58571).

You asked the Plan to waive the coinsurance for a surgical laparoscopy with a total hysterectomy. You say that you should have been considered an inpatient. The Plan denied your request. The Plan says this processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each outpatient hospital facility visit, including physician or surgical charges.

You have been asked to pay a $1,957.23 coinsurance for a surgical laparoscopy with a total hysterectomy ($9,786.13 allowed amount x 20% = $1957.23). The record shows that you were not admitted as an inpatient for this procedure. 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 a surgical laparoscopy with a total hysterectomy (58571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth per quadrant (D4341) for the upper right quadrant and the lower left quadrant.

You asked the Plan to pre-approve periodontal scaling and root planing with dental code D4341. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says based on the documentation provided, there are only 3 teeth in the upper right quadrant and 2 teeth in the lower left quadrant, therefore, these quadrants do not meet the requirements for dental code D4341.

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 as requested. Dental code D4341 is for periodontal scaling and root planning for four or more teeth per quadrant. The file shows that the enrollee does not meet the requirements for dental code D4341 for the upper right quadrant and the lower left quadrant. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth per quadrant (D4341) for the upper right quadrant and the lower left quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Limited oral evaluation - problem focused (D0140) provided November 18, 2020.

You asked the Plan to pay for the Limited oral evaluation. You say that you cannot control the timeframe when services are needed. The Plan denied your request. The Plan says you have exceeded the frequency limits for this 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. The Plan covers the Limited oral evaluation once per year. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the case file confirms that the Plan has already covered one limited oral evaluation for the 2020 calendar year. Therefore, we decided that the Plan does not have to pay for the Limited oral evaluation - problem focused (D0140) provided November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910), porcelain crowns (D2740 x 4), core build up (D2950 x 4), and gingival irrigation (D4921 x 4).

You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested dental services 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, 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 periodontal maintenance (D4910), porcelain crowns (D2740 x 4), core build up (D2950 x 4), and gingival irrigation (D4921 x 4).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis treatments.

You asked the Plan to waive the coinsurance for the dialysis treatments. You say that are appealing the cost share for the dialysis services due to COVID-19. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for in-network Medicare-covered benefits for outpatient dialysis treatments.

The enrollee has been asked to pay $58.20 which is 20% of the allowed amount for each of the dialysis treatments. The allowed amount is $291. ($291 x 20% = $58.20). ($58.20 x 13 treatments = $756.60). The dialysis treatments fall within the "Services to Treat Kidney Disease" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the dialysis treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

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 the services was not filed until October 30, 2020. 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 services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mobile x-ray services (Q0092, R0070) provided November
2, 2020.

You asked the Plan to pay for the mobile x-ray services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the claim was not submitted correctly.

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 CPT codes Q0092, & R0070 are not supported in the medical record. Specifically, these codes
have a Professional Component (PC) / Technical Component (TC) indicator of 3 per the 2020 National
Physician Fee Schedule. The services are not separately payable. Based on this information, we decided that
Medicare rules for coverage of the mobile x-ray services have not been met. Therefore, we decided that the
Plan does not have to pay for mobile x-ray services (Q0092, R0070) provided November 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home health aide services provided from January 2, 2019, to July 24, 2019.

You asked the Plan to reimburse you for the home health aide services. You say that the program covered no more than 8 hours per day and no more than 35 hours per week. The Plan denied your request. The Plan says the provider in this case is not eligible to participate in Medicare. The Plan says that payment cannot be made to providers who are not eligible to participate in Medicare. The Plan says that the dates of services that were overturned in 2017 and 2018 were an exception. The Plan also says that previous letters explained that you must receive care from a provider who is eligible to provide services under Original Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the home health aide services provided from January 2, 2019, to July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. You say that the requested services were necessary for your
health. The Plan denied your request. The Plan says these services are not covered under your dental 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 dental
services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308).

You asked the Plan to pay for nursing facility care. You say that the enrollee did not provide correct insurance
information. The Plan denied your request. The Plan says this was filed more than a year after the date of
service.

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 nursing facility care was not filed until December 3, 2020. 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 nursing facility care (99308).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on October 23, 2020.

You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a "use additional code" at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. 

We find that CPT code 99291 is not supported in the medical record. Specifically, this service was billed with primary diagnosis code R65.21 (Severe sepsis with septic shock). This code cannot be considered as primary, first-listed, principal diagnosis code. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services provided on October 23, 2020.