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

We decided that the Plan does not have to pay an additional amount for the dental services (D0150, D7210, D7140 x 2, D1999, D9230) received January 4 and January 8, 2021, from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services. You say that you were not told that this provider was out-of-network.The Plan denied your request. The Plan says if you receive care from an out-of-network provider you may pay more for services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested additional payment is in excess of what is covered under this benefit. The Plan contract states that when you receive care from an out-of-network provider you may pay more. The Plan provided payment for the requested dental services according to in-network rates. You are responsible for any amount billed by the out-of-network provider that was not covered by the Plan. Therefore, we decided that the Plan does not have to pay an additional amount for the dental services (D0150, D7210, D7140 x 2, D1999, D9230) received January 4 and January 8, 2021, from the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 24, 2020. You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
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 testomg at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that the provider is a hospitalist physician and depends on the hospital staff to verify eligibility and to obtain proper authorization from the patient's insurance company. The Plan denied your request. The Plan says prior authorization is required for services that are provided by an out-of-network provider.
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 skilled nursing services provided on November 25, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 11, 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 37224 and 37220 are not supported.

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 37224 is revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. The definition of code 37220 is revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty.

We find that CPT codes 37224 and 37220 are not supported in the medical record. Specifically, there is no documentation of an open or percutaneous endovascular revascularization of a unilateral femoral or popliteal arteries to support code 37224. There is no documentation of an open or percutaneous unilateral endovascular revascularization of the iliac artery to support code 37220. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on August 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on May 13, 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 code 97110 is not supported.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on May 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.

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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion Interspinous device at L4-L5 is not medically reasonable or necessary. 

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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.

You asked the Plan to pay for foot orthotics. You say that you would like this claim reprocessed and approved for payment because the foot orthotics were medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided to the enrollee from
December 2, 2020, to December 8, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this is an invalid procedure code for this service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We find that HCPCS code S9502 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services
have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502)
provided to the enrollee from December 2, 2020, to December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 5, 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 the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and the emergency transport
(A0427) provided on April 4, 2020.

You asked the Plan to pay for the transportation services. You say that the claim denied because the enrollee
was enrolled in hospice. The Plan denied your request. The Plan says the enrollee's claim would be covered
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until
the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to
verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare
Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on April 3, 2020. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for the ground mileage
(A0425) and the emergency transport (A0427) provided on April 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered from December 15, 2020 to December 16, 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 code 99292 is not supported.

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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).

We find that CPT code 99292 is not supported in the medical record. Specifically, there is no documentation of an additional 30 minutes of critical care time spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered from December 15, 2020 to December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) received June 25, 2020.

You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that this service was performed in preparation for a covered surgery, and so it should also be covered. The Plan denied your request. The Plan says this service is not covered under your 2020 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. The Plan contract specifically states that any services not listed are not covered. The code D0180 is not listed. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) received June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 19, 2020, to September 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you were told that you obtained retro prior authorization. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that 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 psychotherapy services provided on August 19, 2020, to September 10, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Blenrep.

You asked the Plan to pre-approve Blenrep. You say that the enrollee has tried and failed Zometa, Velcade, Darzalex, and Pomalyst. The Plan denied your request. The Plan says the enrollee has not received at least four prior lines of therapy.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Blenrep. Our physician reviewer found that the requested drug is not FDA-approved for the enrollee's condition. FDA approval is for the treatment of relapsed or refractory multiple myeloma in adults who have received at least 4 prior therapies, including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent. This enrollee has only received 2 prior lines of therapy. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Blenrep have not been met. Therefore, we decided that the Plan does not have to pre-approve Blenrep.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (HCPCS E0745) provided to the enrollee on September 3, 2020.

You asked the Plan to pay for the equipment. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code E0745-RR KJ (1 Unit) remains not supported.

The Plan must follow Medicare rules. Medicare rules say that DME supplies must be provided with a proof of delivery. 

The required documentation pertaining to the proof of delivery of these supplies was not provided. Based on this information, we decided that Medicare rules for coverage of the equipment have not been met. Therefore, we decided that the Plan does not have to pay for durable medical equipment (HCPCS E0745) provided to the enrollee on September 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the duplex scans provided on December 30, 2020.

You asked the Plan to waive the copayments for the duplex scans. You say that you shouldn't have copayments. The Plan denied your request. The Plan says you were charged the copayments 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 $160 copayment for each covered radiological diagnostic service for Outpatient Diagnostic tests. 

You have been asked to pay a $160 copayment for each covered radiological diagnostic service for the duplex scans. The duplex scans 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 copayments for the duplex scans provided on December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor.

You asked the Plan to pre-approve a Freestyle Libre 2 Sensor. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Auricular nerve stimulator device (64555, L8679)

You asked the Plan to pre-approve the Auricular nerve stimulator device. You say that please see attached letter and supporting documentation proving medical necessity for this prior authorization request. The Plan denied your request. The Plan says acupuncture for stimulation of auricular points is not a covered Medicare benefit.

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 Auricular nerve stimulator device have not been met. Therefore, we decided that the Plan does not have to pre-approve Auricular nerve stimulator device (64555, L8679)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on January 6, 2021, to January 20, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you tested positive for Covid-19. You say that the Plan is supposed to pay for this 100%. The Plan denied your request. The Plan says the correct copayment 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 $225 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care/in-network.

You have been asked to pay a $225 copayment per day for days 1-7. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,575 ($225 x 7 days = $1,575). The correct copayment has been applied to the inpatient stay that was provided. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating provider on January 6, 2021, to January 20, 2021.