Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea leadless pacemaker.You asked the Plan to pre-approvethe leadless pacemaker. You say that a Micra leadless pacemaker should be implanted rather than transvenous pacemaker. You say that this is because of the enrollee's functional limitations and his recent CVA. You say that there is a concern for him to follow commands which could potentially result in trans-venous pacemaker lead complications.The Plan denied your request. The Plan says the documentation submitted states that the beneficiary is not enrolled in a study. The Plan says that the criteria for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are covered when provided in an FDA approved study or in prospective longitudinal studies.We looked at the file and Medicare rules. The records provided do not show that the enrollee is participating in an FDA approved study or in a prospective longitudinal study. Based on this information, we decided that Medicare rules for coverage of the leadless pacemaker have not been met.Therefore, we decided that the Plan does not have to pre-approvea leadless pacemaker.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on September 30, 2020, by an out-of-network provider.You asked the Plan to pay forthe services. You say that you are requesting reimbursement of services rendered. You state you were aware that this provider is not covered by your plan.The Plan denied your request. The Plan says they made a call to your assigned primary care physician's (PCP) office and the Plan was advised that your PCP did not refer you to this non-participating provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plansays 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 thePlan does not have to pay forthe services provided on September 30, 2020, by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services (92015) provided on February 21,
2020.
You asked the Plan to pay for the eye refraction services. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says eye refraction services are not covered by
Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we
decided that the Plan does not have to pay for the eye refraction services (92015) provided on February 21,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tier exception for Prolia 60MG/ML Syringe (CPT Code J0897).
You asked the Plan to pre-approve the tier exception. You say that you are requesting approval of the drug for continuation of therapy based on the records. The Plan denied your request. The Plan says a tier exception is not feasible under the Medicare tier exception guidance.
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. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met. We are upholding the tier exception request as that does not happen with Medicare Part B coverage. Therefore, we decided that the Plan does not have to pre-approve tier exception for Prolia 60MG/ML Syringe (CPT Code J0897).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the mammogram provided on December
31, 2019.
You asked the Plan to waive the coinsurance for the mammogram. You say that your physician referred you to
have the mammogram. You say you received a bill and paid it. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30%
coinsurance for out-of-network Medicare-covered screening mammograms.
You have been asked to pay $58.19 which is 30% of the allowed amount for the mammogram. The allowed
amount is $193.98. ($193.98 x 30% = $58.19). The mammogram falls within the "Breast cancer screening
(mammogram)" benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the mammogram
provided on December 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy of breast accessed through the skin with ultrasound guidance (19083) provided on June 15, 2020.
You asked the Plan to waive the copayment for the biopsy of breast accessed through the skin with ultrasound guidance. You say that you would like this copayment waived. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Medicare-covered specialist visit. You have been asked to pay a $40 copayment for the biopsy of breast accessed through the skin with ultrasound guidance. The service provided falls within the Medicare-covered specialist visit 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 biopsy of breast accessed through the skin with ultrasound guidance (19083) provided on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimplantable pain pump (CPT Code 62362) and (62350).You asked the Plan to pre-approvethe pain pump. You say that the service is necessary.The Plandenied your request. The Plan says the Medicare rule says that a pain pump is not covered when a member has other implanted programmable devices.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pain pump have not been met. The medical record says the enrollee already has an implanted spinal cord stimulator. The enrollee continues to have breakthrough pain despite the stimulator and oral medications. The Plan cannot approve the second programmable device, as it may conflict with the first device (stimulator).Therefore, we decided that the Plan does not have to pre-approveimplantable pain pump (CPT Code 62362) and (62350).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe limited oral evaluation (D0140) and the extraction (D7210) provided from March 3, 2020, to March 10, 2020.You asked the Plan to reimburse you forthe dental services. You say that you spoke to a plan representative about your tooth breaking. You say that you were advised to get the teeth fixed and to send the bill to her. You say that she advised that you should pay the bill up front and then you would be reimbursed.The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services that you receive from a provider who has opted out of 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 anon-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 forthe limited oral evaluation (D0140) and the extraction (D7210) provided from March 3, 2020, to March 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician certification provided on July
17, 2020.
You asked the Plan to waive the copayment for physician certification for Medicare-covered home health
services (G0180). You say that there has never been a copayment for this service before. The Plan denied your
request. The Plan says you were charged this copayment 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
copayment for Physician Services.
You have been asked to pay a $20 copayment for physician certification for Medicare-covered home health
services (G0180). physician certification for Medicare-covered home health services (G0180) falls within the
Physician Services benefit category. A physician must recertify, every sixty days, that a patient is eligible for
Medicare home health services. 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 physician certification
provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea core buildup, including any pins when required (D2950).You asked the Plan to pre-approvethe core buildup. The Plan denied your request. The Plan says this service is 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-approvea core buildup, including any pins when required (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve
acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve  IRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a compression calf/foot wrap (E1399) for the enrollee.
You asked the Plan to pre-approve the wrap. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not the appropriate code to use.
The Plan must follow Medicare rules. Medicare rules say that surgical dressings are covered for as long as they are reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the wrap. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found i n this case, the documentation indicates that the enrollee has bilateral lower extremity lymphedema with papillomas, hyperkeratosis and a reg leg venous ulcer. She has tried and failed standard compression wraps. The review has determined that the requested compression calf/foot wrap (E1399) is medically necessary and reasonable. 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 wrap have been met. Therefore, we decided that the Plan has to pre-approve a compression calf/foot wrap (E1399) for the enrollee.
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: Drugs
Decision: Unfavorable

e decided that the Plan does not have to pre-approveEntresto 24 mg-26 mg tablet.You asked the Plan to pre-approveEntresto24 mg-26 mg tablet. You say that the item is medically necessary.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approveEntresto 24 mg-26 mg tablet.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical procedures on the biliary tract and incision
procedures on the liver (biopsy of liver), provided on December 10, 2019.
You asked the Plan to pay for the surgery and biopsy. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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 procedures on the biliary tract and incision procedures
on the liver (biopsy of liver), provided on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs LTACH services.The Plan denied your request. The Plan says the enrollee needs to stay in the hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora Lumbar-Sacral orthosis, Wrist-Hand orthosis, and Ultraviolet light therapy system (E0691, L0648, L3916) provided August 10, 2020.You asked the Plan to pay forthe medical equipment. You say that the items were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met, therefore the requested equipment is non-covered.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. The record showsno previous in-person or telehealth visits with the ordering provider, or any evidence of a previous relationship between the physician and patient. There were no claims submitted for an evaluation and management service. Consequently, the items ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay fora Lumbar-Sacral orthosis, Wrist-Hand orthosis, and Ultraviolet light therapy system (E0691, L0648, L3916) provided August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transcutaneous electrical nerve stimulation (TENS) device (E0730) provided on December 9, 2019.You asked the Plan to pay forthis item. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says that a transcutaneous electrical nerve stimulator (TENS) and supplies for the treatment of chronic low back pain are not a covered benefit under the enrollee's contractual policy or by Medicare.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 case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met.Specifically, the claim was billed with a diagnosis code for chronic pain. Themedical notes indicated by the physician on November 27, 2019, state a history of chronic low back pain syndrome secondary to lumbar disc disease andlumbar disc herniation. Medicare rules state that a TENS device is not reasonable and necessary for the treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pay forthe transcutaneous electrical nerve stimulation (TENS) device (E0730) provided on December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection (87798) provided on May 8, 2020.
You asked the Plan to pay for the infectious agent detection. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says this service is not a Medicare covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the infectious agent detection, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for infectious agent detection (87798) provided on May 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing (81455) provided August 20, 2020.You asked the Plan to pay forthe genetic testing. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim was not billed using the correct CPT code.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 81455 is not supported in the medical record. Specifically, per Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile SequencingTesting in Solid Tumor Cancers (A55624), comprehensive genetic testing must be billed using CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forgenetic testing (81455) provided August 20, 2020