Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 physician services provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 2, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section. 

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 and suspension sleeve. Our reviewer says that the item was not medically reasonable and necessary. Our physician reviewer found There is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, 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 and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism (E0627) purchased September 24, 2020, from a provider not certified with Medicare.

You asked the Plan to pay for the seat lift mechanism. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this service is excluded from coverage.

The Plan must follow Medicare rules. Medicare rules say that a provider must be enrolled in the Medicare program to receive payment. 

We looked at the file and Medicare rules. The provider in this case you purchased the item from is not certified with Medicare. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism (E0627) purchased September 24, 2020, from a provider not certified with Medicare.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs to get well at a SNF. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee has a medical history including chronic obstructive pulmonary disease (COPD) and was admitted to an acute hospital due to respiratory failure. The most recent therapy documentation indicates that the member is dependent for mobility and self-care tasks and is medically stable but continues to require ventilation by a machine for breathing. The enrollee has been receiving skilled services in a long-term acute care hospital (LTACH). The enrollee is unable to make progress with therapy due to hypoxic brain damage resulting in cognitive impairment and there is no indication that transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled services at the current level of care in an LTACH and when medically appropriate be stepped down to a lower level of custodial care. There are no services offered at a SNF that are not offered at a LTACH.

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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization.

You asked the Plan to pre-approve prostate artery embolization. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of prostate artery embolization in the setting of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) have not been demonstrated in the peer reviewed literature.

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 prostate artery embolization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Artery Embolization (PAE) for the treatment of LUTS secondary to BPH is not supported by current data and trial designs, and benefit over risk remains unclear; therefore, PAE is not recommended outside the context of clinical trials. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483).

You asked the Plan to pre-approve a high frequency chest wall oscillation system. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a high frequency chest wall oscillation system. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no diagnosis of cystic fibrosis. There is no diagnosis of bronchiectasis confirmed by a computed tomography (CT) scan. There is no evidence of a neuromuscular disease from the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses. Coverage criteria have not been met for the E0483 device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a high frequency chest wall oscillation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 20, 2021.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 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 January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 18, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you never saw the doctor. 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 $25 copayment for a specialist visit. 

The medial records show that you had a specialist visit on September 18, 2020. Therefore, you are responsible to pay the $25 copayment. 

You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0220, D2330).

You asked the Plan to pay for the dental services (D0220, D2330). You say that the services were necessary for you to be able to eat. The Plan denied your request. The Plan says the requested services are not covered by your plan's supplemental 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 (D0220, D2330).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on October 9, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes Q0092 and R0070 are not separately payable.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component
(TC) indicator of 3 represents TC only codes.

We looked at the file and Medicare rules. Billed procedure codes Q0092 and R0070 have a PC/TC indicator of
3 and no separate professional component payment. Therefore, we decided that the Plan does not have to pay
for the mobile x-ray services rendered on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided out of network on November 10, 2020.

You asked the Plan to pay for these services. You say that the Plan should cover these services. The Plan denied your request. The Plan says you did not have prior authorization for out of network vision services.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 vision services provided out of network on November 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a
participating provider on November 24, 2020.

You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you have never had to pay
for this before. 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). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for outpatient surgery.

You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total
allowed amount is $1,151.72. The total amount you are being asked to pay is $230.24 ($1,151.72 x 20% =
$230.34 an outpatient surgery falls within the outpatient surgery 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 an outpatient surgery provided by a participating provider on November 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the diagnostic testing services provided on October 6, 2020.

You asked the Plan to waive the copays for the services provided. You say that you should not have been charged for a screening mammography. The Plan denied your request. The Plan says the claim was 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 $10 copay for most x-rays and ultrasounds. 

The file shows that you received a diagnostic mammogram, a breast ultrasound, and a breast tomosynthesis on October 6, 2020. You have been asked to pay a $10 copay for each of the testing services. The services fall within the outpatient diagnostic tests 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 copays for the diagnostic testing services provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion or replacement of spinal neurostimulator pulse generator or receiver.

You asked the Plan to pay for the insertion or replacement of spinal neurostimulator pulse generator or receiver. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the insertion or replacement of spinal neurostimulator pulse generator or receiver. Our reviewer says that CPT code 63685 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate an insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling being performed on September 10, 2020, therefore, this service cannot be verified. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion or replacement of spinal neurostimulator pulse generator or receiver have not been met. Therefore, we decided that the Plan does not have to pay for the insertion or replacement of spinal neurostimulator pulse generator or receiver.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) provided on December 3, 2020.

You asked the Plan to pay for the oral evaluation. You say that you only had one tooth removed and this benefit should not be exhausted. The Plan denied your request. The Plan says they paid for a problem-focused oral evaluation for you in August of 2020. The contract states that a problem-focused evaluation can only be covered once per plan year.

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 evaluation can only be covered once per plan year. The Plan provided documentation that you also had this service in August of the same year, and therefore the benefit for a problem-focused evaluation had been exceeded on the date in question. Therefore, we decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) provided on December 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bystolic.

You asked the Plan to pre-approve Bystolic. You say that the enrollee has been on Bystolic for over a year with good results. The Plan denied your request. The Plan says Bystolic to be administered at home is not covered under the 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 Bystolic.

Benefits for Bystolic 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the thyroidectomy (60240).

You asked the Plan to pay for the thyroidectomy. You say that you would like reconsideration because these
medically necessary services were rendered in good faith. The Plan denied your request. The Plan says this
CPT code refers to all four parathyroid glands and is not reported as a unilateral procedure.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We asked our coder 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 thyroidectomy. Our reviewer says that
CPT code 60240 AS LT does not meet criteria for billing or reimbursement consideration. Our reviewer found
the Modifier Crosswalk does not offer RT/LT as a modifier option for this code. CPT code 60500 has a
bilateral indicator of 0, indicating that there is no bilateral payment adjustment.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the thyroidectomy have not been met. Therefore, we decided that the Plan does
not have to pay for the thyroidectomy (60240).
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 the effectiveness of this device in the setting of lumbar spinal stenosis has not been demonstrated in peer-reviewed literature.

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 this device is experimental and more research is needed to determine 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression sleeve identified with code A6549.

You asked the Plan to pre-approve the compression sleeve. You say that the enrollee needs a compression
sleeve to prevent progression of lymphedema. The Plan denied your request. The Plan says compression
sleeves do not meet the definition of a surgical dressing.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression sleeve
identified with code A6549.