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

We decided that the Plan does not have to pay for limited oral exam (D0140) intraoral periapical first x-ray (D0220) provided October 28, 2020.

You asked the Plan to pay for the dental services. You say that the assistant at the counter told you that she contacted the plan and was told the coverage was okay. The Plan denied your request. The Plan says these services are not covered under the plan benefits.

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 health plan contract says that any services not listed under the Description of Benefits are not covered. 

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 limited oral exam (D0140) intraoral periapical first x-ray (D0220) provided October 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76705).

You asked the Plan to pay for an ultrasound. You say that this procedure is not limited to a specific POS. The Plan denied your request. The Plan says this was not billed with the correct POS.

The Plan must follow Medicare rules. Medicare rules say that when a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.

We looked at the file and Medicare rules. The record shows that the service at issue was billed with POS 22, but the enrollee was a registered inpatient at the time of service. Based on this information, we decided that Medicare rules for coverage of an ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76705).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not meet the Medicare criteria for a therapeutic CGM and the documentation does not indicate that the enrollee has failed use of a preferred brand of CGM.

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 the enrollee does not 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. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an infusion provided by a participating provider on May 9, 2020, to May 15, 2020.

You asked the Plan to waive the coinsurance for an infusion. You say that you should not have to pay for this because the pump was not programmed correctly. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs/in-network. 

The enrollee has been asked to pay a 20% coinsurance of the allowed amount for an infusion. The total allowed amount is $403.13. The total amount you are being asked to pay is $80.64 ($403.13 x 20%= $80.64). The correct coinsurance has been applied to the infusion that was supplied. Infusions fall within the Medicare Part B prescription drugs/in-network 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 an infusion provided by a participating provider on May 9, 2020, to May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667x2).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that due to existing truncal swelling and significant pain, you have determined the enrollee would not benefit from treatment from a basic pump. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667x2).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Abraxene.

You asked the Plan to pre-approve Abraxene. You say that this drug is medically necessary for your condition. The Plan denied your request. The Plan says the denial of authorization for Abraxene is correct, because the Plan requires a trial of Taxol or Taxotere before it will approve Abraxene and there is no indication that these preferred drugs would be less effective or cause adverse effects for you.

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 Abraxene. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Abraxene. Our physician reviewer found the documentation does not show that you have tried and failed the Plan's preferred drugs of Taxol or Taxotere. The documentation does not support that these drugs would likely be less effective and/or have adverse effects for you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxene have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Abraxene.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs close monitoring. The Plan denied your request. The Plan says the enrollee's needs are custodial.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no identifiable skilled nursing service needs. While she has skilled therapy needs, she does not require skilled therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the premium lens, eye drops and eye patches.

You asked the Plan to reimburse you for the premium lens, eye drops and eye patches. You say that you should be reimbursed for wound care supplies and the difference of premium lenses and conventional lenses. The Plan denied your request. The Plan says the premium lens package, eye drops and eye patches are not covered by Medicare or the Plan.

The Plan covers all items that Medicare covers. Medicare rules say that the astigmatism-correcting feature of an IOL is not covered by Medicare. You can find this rule in the CMS Ruling, No. CMS-1536-R, "Astigmatism-Correcting IOLs", January 22, 2007.

While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. You were given and signed the notice that Medicare does not cover the premium IOLs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Medicare does not cover disposable eye patches. Therefore, we decided that the Plan does not have to reimburse you for the premium lens, eye drops and eye patches.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation services and supplies provided on August 28, 2020.

You asked the Plan to pay for the air ambulance transportation services and supplies. 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 payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that supplies are not paid separately for ambulance services. 

We find that the air ambulance services provided were billed with place of treatment 4. Place of treatment 4 is not a valid place of treatment for ambulance services. Also, supplies are not paid separately for ambulance services. Based on this information, we decided that Medicare rules for coverage of the air ambulance transportation services and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation services and supplies provided on August 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa Capsules.

You asked the Plan to pre-approve Vascepa Capsules. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 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 Vascepa Capsules.

Benefits for Vascepa Capsules 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided on April 23, 2020, and April 24, 2020.

You asked the Plan to pay for critical care. You say that this should be covered. The Plan denied your request. The Plan says this is not supported in the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We find that CPT code 99291 is not supported in the medical record. Specifically, no medical records for the billed dates of service have been submitted. Without this documentation, the billed codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on April 23, 2020, and April 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve.

You asked the Plan to pay for the knee orthosis (L1833RT) and suspension sleeve (L2397RT). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the prescribing physician never saw the enrollee.

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 knee orthosis (L1833RT) and suspension sleeve (L2397RT). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis (L1833RT) and suspension sleeve (L2397RT) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.

You asked the Plan to pre-approve these services. You say that you need treatment as soon as possible. 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 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. The Plan confirmed that the network providers are able to treat the enrollee. 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 cardiologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis (L3916).

You asked the Plan to pay for wrist hand orthosis. You say that this item was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the documentation provided does not substantiate that the provider had an examination with the enrollee.

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 wrist hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found an appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthoses were medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the wrists. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis (L3916).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of inpatient skilled nursing facility care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pre-approve SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you are currently in an inpatient rehabilitation facility. From a nursing perspective, you have received oral and topical medications; and have had stable vital signs. You were treated for right lower extremity pain. You have received physical and occupational therapy. You were at a moderate to maximal assistance with functional mobility and could propel your wheel chair with supervision. You have required varying assistance with activities of daily living. You have worked with speech therapy on dysphagia and cognitive deficits. You do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq tablets.

You asked the Plan to pre-approve Myrbetriq tablets. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.

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 Myrbetriq tablets.

Benefits for Myrbetriq tablets 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and periodontal maintenance provided by an OON provider.

You asked the Plan to pay for the first intraoral periapical x-ray and periodontal maintenance. You say that you believe you should be able to choose your own dentist and have the services covered. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that services are only covered when they are received from a participating provider.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and periodontal maintenance provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist.

You asked the Plan to pre-approve these services. You say that the enrollee needs medical attention. 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 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. The Plan confirmed that the network provider specializes in treating your diagnosis. 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 dermatologist.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the chest x-ray (70450) provided on September 2, 2020.

You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says that CPT code 70450 is a column II code to another code that was billed on the same date of 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. 

We find that CPT code 70450 is supported in the record. Specifically, the documentation submitted indicates that the column I and column II services were rendered by different providers. NCCI edits apply to line items for the same beneficiary, same NPI and same date of service. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met. Therefore, we decided that the Plan has to pay for the chest x-ray (70450) provided on September 2, 2020.