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

We decided that the Plan does not have to pre-approve the group 3 power wheelchair and accessories (K0862, K0108, E1007, E2300, E2311).

You asked the Plan to pre-approve the group 3 power wheelchair and accessories. You say that these items are medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 group 3 power wheelchair and accessories. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found that the documentation indicates that the patient has a mobility limitation that impairs MRADLs in the home, but the patient's mobility limitation is able to be helped by the use of a manual wheelchair.

While the patient may be able to safely operate the requested K0862 wheelchair and has a Group 3 diagnosis, the requested K0862 wheelchair and accessories are not medically necessary as the documentation does not support that the K0862 will significantly improve MRADL participation in the home. 

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 group 3 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 3 power wheelchair and accessories (K0862, K0108, E1007, E2300, E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
received January 25, 2021.
You asked the Plan to pay for the limited oral evaluation - problem focused (D0140). You say that you had a
filling fall out and needed to go to the dentist. The Plan denied your request. The Plan says problem focused
oral evaluations are not covered under your 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 offers coverage for routine oral evaluations. There is no
coverage for problem focused oral evaluations. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation - problem focused (D0140) received January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057), and the abutment
supported crown (D6061) provided on January 14, 2021.
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you
believe that this denied in error. You say that your coverage document expressly states that crowns are covered
once within 84 months per tooth at 50%. You say that the original tooth could not be restored. You say that this
should be paid at 50% as provided in the plan document. You also say that the services you received did not
include implants. The Plan denied your request. The Plan says implant related services are not covered.
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 record shows that abutments and abutment supported crowns are
implant supported structures, thus implant related services. Therefore, we decided that the Plan does not have
to pay for the custom fabricated abutment (D6057), and the abutment supported crown (D6061) provided on
January 14, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on June 26, 2020.

You asked the Plan to pay for lab tests. You say that the treating physician ordered this testing as a safe and effective method to aid in evaluating the probability of organ rejection for the enrollee. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on June 26, 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 waive the coinsurance for a Denosumba injection provided by a participating provider on June 3, 2019, to December 2, 2019.

You asked the Plan to waive the coinsurance for an injection. You say that you believe these shots should be covered. 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 10% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 10% coinsurance of the allowed amount for an injection. The total allowed amount is $2,277.96. The total amount you are being asked to pay is $227.80 ($2,277.96 x 10% = $227.80). The correct coinsurance has been applied to the injections that were provided. An injection falls within the Medicare Part B prescription drugs 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 a Denosumba injection provided by a participating provider on June 3, 2019, to December 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on November 19, 2020.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges because you only received an assessment and could never get on the provider's schedule. 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 $40 copayment for outpatient rehabilitation services.

You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 outpatient rehabilitation services provided on November 19, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio 300mg every 4 weeks.
You asked the Plan to pre-approve Entyvio 300mg every 4 weeks. You say that the enrollee's dosing should be increased to every 4 weeks to see the most optimal outcomes possible. The Plan denied your request. The Plan says that the requested dosage is more than the maximum allowed dose for the enrollee's indication.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 Entyvio 300mg every 4 weeks. Our reviewer says that the requested service is recommended. Our physician reviewer found the Entyvio is effective, but symptoms recur prior to the next due dose. The requested drug is being used for its labelled indication. The medical record supports that the requested drug is medically necessary for the enrollee. The elements of the coverage criteria are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio 300mg every 4 weeks have been met. Therefore, we decided that the Plan has to pre-approve Entyvio 300mg every 4 weeks.
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: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (G0483) provided on October 15, 2020.

You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says that the records do not show that 22 or more drug classes were tested.

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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.

We find that CPT code G0483 is supported in the medical record. Specifically, the submitted medical records show that 24 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on October 15, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One-Touch diabetic test strips.

You asked the Plan to pre-approve the One-Touch diabetic test strips. You say that you have a One-Touch monitor already and would like to continue using it. The Plan denied your request. The Plan says Accu-chek is the preferred brand. You can obtain an Accu-chek monitor covered by the plan.

The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands. 

We looked at the file and Medicare rules. No medical records were provided to show that the plan preferred brand, Accu-Chek, would be unsafe or ineffective for the enrollee. Based on this information, we decided that Medicare rules for coverage of the One-Touch diabetic test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One-Touch diabetic test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on May 29, 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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS
suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 lumbar-sacral orthosis (LSO) rendered on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks.

You asked the Plan to pre-approve medial branch blocks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 medial branch blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have chronic low back pain with a differential diagnosis of spinal stenosis, facet arthropathy and sacroiliitis. You take Percocet and was also given morphine which helped in the Emergency Department. National coverage guidelines consider facet mediated pain as a diagnosis of exclusion. You have other probable pain generators that should be addressed first. Therefore, you do not meet criteria for the requested services.

Review of the file shows that the Plan uses Local Coverage Determination (LCD) L35996 to support their denial. However, this LCD has expired. Therefore, we are unable to use LCD L35996 to substantiate our decision. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 21, 2020.

You asked the Plan to waive the copayment for the colonoscopy. You say that this was your first colonoscopy with this policy, and you were led to believe it was covered. 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 $400 copayment for Outpatient Surgery. 

You have been asked to pay a $400 copayment for the covered colonoscopy. The colonoscopy 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 copayment for the colonoscopy provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 2, 2020 by a non-participating provider.

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 services were rendered by a non-participating provider without prior authorization.

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 the laboratory services provided on November 2, 2020 by a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revision of total knee arthroplasty services coded 27486
provided on December 27, 2019.

You asked the Plan to pay for the revision of total knee arthroplasty services. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not
supported by the documentation.

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 27486 is revision of total knee arthroplasty, with or without allograft; 1 component.

We find that CPT code 27486 is not supported in the medical record. Specifically, the operative report did not
include documentation of a revision of total knee arthroplasty, with or without allograft; for 1 component;
therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage
of the revision of total knee arthroplasty services have not been met. Therefore, we decided that the Plan does
not have to pay for the revision of total knee arthroplasty services coded 27486 provided on December 27,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on November 5, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a 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. Cardiovascular risk assessment panels are only covered for certain indications.

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36523 to substantiate our decision.

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on November 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on September 29, 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 97530 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the records support that services were rendered by an occupational therapist in the home setting and there is a more appropriate home
health 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 occupational therapy services rendered on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant
(D6010 x10) and the treatment of root canal obstruction; non-surgical access (D3331 x2) received December
14, 2020.
You asked the Plan to pay for the implants and the root canal treatment. You say that the requested procedures
were necessary for your health. The Plan denied your request. The Plan says the requested procedures are not
covered under your 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
surgical placement of implant body: endosteal implant (D6010 x10) and the treatment of root canal obstruction;
non-surgical access (D3331 x2) received December 14, 2020.