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

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support interspinous spacer devices as safe and effective as the gold standard of decompression.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including the planned level of implantation L3-L4 and L4-L5).

FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension films. There is imaging evidence of dextroconvex curvature of the lumbar spine centered at L3, with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. Overall, there is no 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 L3-L4 and 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision eye exam provided on April 9, 2021.

You asked the Plan to pay for the routine vision eye exam. You say that you felt misled to get a routine eye exam and believe that the additional cost is unfair. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits. The Plan states they advised the provider of your concerns that you were not informed in advance of the additional costs associated with a routine vision exam. The Plan states they confirmed with Alexandra, a courtesy adjustment of $115.00 has been made to your account.

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. 

We looked at the file and the Plan's rules. Review of the file shows that the Plan paid the maximum benefit amount of $75 for the routine vision eye exam provided on April 09, 2021. Any charges above the benefit maximum of $75.00 for the routine vision eye exam is your responsibility. Based on the information above, the Plan is unable to make an additional payment for your routine vision eye exam provide on the above-listed date. Therefore, we decided that the Plan does not have to pay for the routine vision eye exam provided on April 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan (93882, 93880).
You asked the Plan to pre-approve the duplex scan. You say that the duplex scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that for this test dizziness is not a typical indication unless associated with other localizing neurologic signs or symptoms. 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 duplex scan. Our reviewer says that the requested carotid duplex scan is not medically necessary. Our physician reviewer found the record shows that neurologic examination is normal. Physical examination of the carotids is unremarkable. The requested test is not typically indicated for dizziness unless associated with other localizing neurologic signs or symptoms.
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 duplex scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan (93882, 93880).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic testing (CPT code 86769) provided to the enrollee on July 27, 2020.

You asked the Plan to pay for the testing. You say that the services were necessary. The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a 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. 

These services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes. This is not a COVID screen test. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular genetic testing (CPT code 86769) provided to the enrollee on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99213) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visit. You say that this provider is one of the leading oncologists. You state you need second opinion because the current treatment you are receiving is not working. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 

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 office visit. Our physician reviewer found there is no specific clinical rational provided for the out-of-network referral. The records do not indicate that the care provided (or requested) was/is medically necessary. There are in-network providers available. 

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 office visit have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. 

We found no exception that would require the Plan to pre-approve the office visit. Therefore, we decided that the Plan does not have to pre-approve the office visit (CPT code 99213) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) (CPT code 62321) provided to the enrollee on March 18, 2021.

You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 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 injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) (CPT code 62321) provided to the enrollee on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7286) for the enrollee.

You asked the Plan to pre-approve the services. You say that the tissue lesion is possibly cancerous. The Plan denied your request. The Plan says this is not a covered 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 pre-approve dental services (D7286) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospice care provided on December 21, 2020.

You asked the Plan to pay for the hospice care. The Plan denied your request. The Plan says hospice care is not covered on the date of death.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospice care provided on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing services provided on July 20, 2020.

You asked the Plan to pay for the testing services. You say that the ordering physician attested to the Medicare coverage criteria. The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.

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 looked at the file and the rules. We find that the testing services were not billed with a CPT code that is eligible for payment. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing services provided on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cochlear implant for the enrollee.

You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the current criteria.

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 implant. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee had congenital rubella syndrome with resultant deafness. The enrollee has a left cochlear implant. The enrollee underwent a recent hearing test with a score of 45%. The record does not indicate that the enrollee is enrolled in either an FDA-approved category B investigational device exemption clinical trial as defined at 42 CFR 405.201, a trial under the Centers for Medicare & Medicaid (CMS) Clinical Trial Policy as defined at section 310.1 of the National Coverage Determinations Manual, or a prospective, controlled comparative trial approved by CMS as consistent with the evidentiary requirements for National Coverage Analyses and meeting specific quality standards. The elements of the coverage rule are not 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 the implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a cochlear implant for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): U0005L, and U0003L) provided on January 19, 2021.

You asked the Plan to pay for the laboratory services. You say that you should not have to pay anything. The Plan denied your request. The Plan says the provider still needs to submit claim for the services provided to your primary insurance, then send the explanation of benefits to the Plan in order for claim to be paid.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan needs the explanation of benefits (EOB) from the primary insurance. As the secondary insurer, the Plan cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): U0005L, and U0003L) provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out of network (OON) provider on October 5, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307) rendered by the out of network (OON) provider on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (CPT code L1833), and suspension sleeves (L2397) provided to the enrollee on December 10, 2020.

You asked the Plan to pay for the orthoses and sleeves. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.

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 orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. 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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (CPT code L1833), and suspension sleeves (L2397) provided to the enrollee on December 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (CPT code A0428), for the enrollee.

You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the enrollee needs treatment to sustain life. The Plan denied your request. The Plan says the medical documentation received does not support this service because there is no medical need for the enrollee to require an ambulance.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 non-emergency ambulance transportation. Our physician reviewer found the enrollee doesn't tolerate sitting for longer periods of time and does use a wheelchair for mobility with assistance. Other means of transportation such as a wheelchair van or stretcher van were not contraindicated according to the documentation. The documentation does not support that an expert attendant was required for hemodynamic monitoring and oxygen could be provided in non-ambulance transport. The enrollee is hemodynamically stable. The documentation does not support that the ambulance services are medically 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 non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transportation (CPT code A0428), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the custom oral device (E0486).
You asked the Plan to pre-approve the custom oral device. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the requested device would be used for the teeth and would be considered dental in nature.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the custom oral device. Our reviewer says that the requested custom orthosis is medically necessary for the enrollee's condition. Our physician reviewer found the supplied documentation does support the billed diagnosis of TMJ disorder. The records indicate muscle soreness in the masseter and pterygoid muscles. It was noted that there were occlusal interferences that maty be contributing to the muscle soreness in the area of the jaws. In this case, the documentation indicates that the appliance is focused on the medical condition of pain in the jaw due to possible occlusal interferences. The notes indicate that the appliance would be for the purpose of eliminating posterior interferences which presumably could trigger TMJ disorders. An oral appliance would be appropriate for this patient to allow for assessment of the TMJ disorder and muscle pain that may be in part attributable to the occlusal interferences with a reversible modality. 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 custom oral device have been met. Therefore, we decided that the Plan has to pre-approve the custom oral device (E0486).
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 inpatient services rendered on February 15, 2021.

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 enrollee was not under inpatient status.

The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 21. 

We looked at the file and Medicare rules. The file shows that the enrollee was not under inpatient status for the date of service at issue. 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 initial inpatient services rendered on February 15, 2021.