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

We decided that the Plan does not have to pre-approve the power wheelchair modifications to the approved power wheelchair.

You asked the Plan to pre-approve power wheelchair anterior tilt feature or transfer handles. You say that the enrollee has significant leg weakness and is unable to stand. The Plan denied your request. The Plan says anterior tilt and transfer handles are not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Power anterior tilt has the same function as the power seat elevation feature and is not covered by Medicare or the Plan. The transfer handles do not serve a medical purpose.

Therefore, we decided that the Plan does not have to pre-approve the power wheelchair modifications to the approved power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 19, 2020.

You asked the Plan to pay for the comprehensive evaluation. You say that you went to a new dental provider, and they would not accept you as a patient without performing their own comprehensive evaluation first. The Plan denied your request. The Plan says comprehensive oral evaluations will only be paid for once every three years. The Plan previously paid for a comprehensive oral evaluation for you in November of 2020, which is less than 3 years prior. Therefore, this benefit was exhausted at the time of 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 exceeded the frequency allowed under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular screening provided on September 10, 2020.

You asked the Plan to pay for the cardiovascular screening. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

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 cardiovascular screening. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member already is at at very high future risk for recurrent cardiovascular events so genetic variant risk screening would not add additional information for management of this clinical situation. He has known severe cardiovascular disease and should already be aggressively treated according to guideline directed therapy for optimal future cardiovascular risk modification. The results of a cardiovascular genetic risk screening panel would not change this management strategy based on published AHA/ACC guidelines. 

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 cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular screening provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive no-line multifocal lenses provided November 3, 2020.

You asked the Plan to pay for the progressive lenses. You say that you would like the eyewear covered. The Plan denied your request. The Plan says since the eyewear was provided by an out-of-network provider, it is not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when eyewear is purchased from a participating provider. 

We looked at the file and the Plan's rules. You purchased lenses from a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the progressive no-line multifocal lenses provided November 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT of the Thorax (71250) provided on October 29, 2020.

You asked the Plan to pay for the CT of the Thorax. You say that you would like reconsideration because you were told by your provider that this service would be covered. The Plan denied your request. The Plan says repeat imaging is not supported unless prior imaging results show a clear reason for it.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 pay for the CT of the Thorax. Our reviewer says that a repeat CT scan of the chest is considered not medically necessary. Our physician reviewer found there is an order for a chest CT to be done in March 2020, but it is unclear whether that was done. If it was done and the nodule was stable, then no further follow-up would have been indicated. Without additional documentation, it is unclear whether another chest CT is necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT of the Thorax have not been met. Therefore, we decided that the Plan does not have to pay for CT of the Thorax (71250) provided on October 29, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the COVID test provided on September 23, 2020.

You asked the Plan to pay for the COVID test. The Plan denied your request. The Plan says that the provider is not in-network and there is no authorization on file.

The Plan must follow Medicare rules. Medicare rules say that plans may not impose any prior authorization or other utilization management requirements with respect to COVID-19 testing and testing-related services. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID test have been met. Therefore, we decided that the Plan has to pay for the COVID test provided on September 23, 2020.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care services coded 99304 provided on October 7, 2020.

You asked the Plan to pay for the initial nursing facility 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 99304 is initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. 

We find that CPT code 99304 is not supported in the medical record. Specifically, this code was billed with place of service 21 (inpatient). This code was billed with an inappropriate place of service. Based on this information, we decided that Medicare rules for coverage of the initial nursing facility care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care services coded 99304 provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cochlear implantation for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says there must be a diagnosis of bilateral hearing loss.

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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has normal hearing on the right with a very mild drop at 8000 Hz. There is no diagnosis of
bilateral hearing loss. There is no coverage for this procedure in the case of single-sided deafness.

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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve cochlear implantation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the soft tissue grafting procedures (D4277, D4278) provided on October 28, 2020.

You asked the Plan to pay for the grafting procedures. You say that this was a medically necessary procedure and should be covered. The Plan denied your request. The Plan says these procedures are not covered by Medicare or by the Plan's supplemental 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 soft tissue grafting procedures (D4277, D4278) provided on October 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $250 copayment charged for emergency response without transport.

You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says you had emergency response services respond after a fall. There was no transport. Typically, Medicare does not pay for these services. The Plan pays for these services with a $250 copayment expectation from the enrollee.

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 $250 copayment for emergency response without transport. This is not covered by Medicare and you could have been responsible for the entire cost of $439. Because the Plans coverage exceeds Medicare's, you are only required to pay $250. 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 $250 copayment charged for emergency response without transport.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the remaining neuromonitoring services provided on July 21, 2020.

You asked the Plan to pay for the neuromonitoring services (95939, 95938, 95861, 95868, 95927). You say that this claim should be paid. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary during an inpatient stay. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. 

This was an inpatient service. Payment for this service would have been included under the global facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for the remaining neuromonitoring services provided on July 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pulmonary diagnostic testing provided on January 15, 2021.

You asked the Plan to waive the copayment for pulmonary diagnostic testing. You say that you paid your specialist copayment and disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $20 copayment for outpatient diagnostic procedures and tests. 

You have been asked to pay a $20 copayment for pulmonary diagnostic testing. Pulmonary diagnostic testing falls within the outpatient diagnostic tests and therapeutic services and supplies 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 pulmonary diagnostic testing provided on January 15, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.

You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says you have not tried
and failed Orthovisc, Synvisc, and Synvisc One.

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 Hyalgan. Our physician reviewer found
that you have a history of osteoarthritis of the knees. The Plan requires a trial of Orthovisc, Synvisc, and
Synvisc One before they will approve the requested drug. In this case, you have not tried and failed the
required drugs. There is no documentation indicating that the plan's required drugs would likely be less
effective, or likely have adverse effects.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hyalgan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 17, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 physician's services. 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 physician's services provided on November 17, 2020.
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 for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 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 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 pre-approve SNF care. Our reviewer says that
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee
does not have documented skilled nursing or skilled therapy needs. The enrollee is currently unable/unwilling
to participate in skilled therapy services. Daily skilled services are not required to establish a maintenance
program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are
custodial and, as a practical matter, can be provided at a lower 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 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: SNF
Decision: Favorable

We decided that the Plan has 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 for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet 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 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 pre-approve SNF care. Our reviewer says that inpatient skilled nursing facility care is medically necessary. Our physician reviewer found that the enrollee's weight bearing status was advanced on April 9, 2021. At that time, the enrollee did not have documented skilled nursing needs, but she did have documented skilled therapy needs. Daily skilled services were required to establish a maintenance program, prevent deterioration of the enrollee's condition and/or improve her overall strength and endurance. 

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 been met. The Plan must continue coverage for the SNF skilled service until such time the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve inpatient skilled nursing facility (SNF) care.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cardiovascular stress test provided on January 6, 2021.
You asked the Plan to waive the deductible for the cardiovascular stress test. You say that you pay monthly for this benefit so the service should be covered, and the deductible waived. The Plan denied your request. The Plan says you had not met your deductible at the time of service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible for covered medical services. The item or service you asked the Plan to waive the deductible for falls within the benefit category medical covered services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for diagnostic laboratory labs, tests, and x-rays. This cost sharing is a contractual obligation that had not been met at the time the cardiovascular stress test was received on January 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the cardiovascular stress test provided on January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration
because this procedure is medically necessary. The Plan denied your request. The Plan says this service is
experimental.
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 Vertiflex Superion Spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the Vertiflex device is experimental, and more research is needed to show
its safety and efficacy.
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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the
Plan does not have to pre-approve the Vertiflex Superion Spacer.