Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for your second shingles vaccine provided on September 29, 2020.
You asked the Plan to pay for your second shingles vaccine. You say that the first shot was paid for by the Plan and then you were told it was now free. The Plan denied your request. The Plan says your initial injection payment in 2019 was reversed as a courtesy.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide your second shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to your second shingles vaccine. Therefore, we decided that the Plan does not have to pay for your second shingles vaccine provided on September 29, 2020.
Benefits for your second shingles vaccine 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on September 7, 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 services are not covered.

The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under code 81455 will be denied as not medically necessary. 

We looked at the file and Medicare rules. The services at issue are genetic testing billed with code 81455. These services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered on September 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 24, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that your copayment should be waived because you have a family history of cancer and fibroid cysts, and your doctor is recommending a breast ultrasound every six months. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $325 copayment per day for Medicare-covered diagnostic radiology services ($100 ultrasound). You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services provided on November 6, 2020.
You asked the Plan to waive the copayment for ophthalmology services. You say that this was for glaucoma testing and you should not owe a copayment. 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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for ophthalmology services. Ophthalmology services fall 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 ophthalmology services provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown and resin-based composite of two surfaces, or pay more for the resin-based composite of three surfaces and resin-based composite of four or more surfaces provided on September 3, 2020 by an OON provider.

You asked the Plan to pay for the re-cement or re-bond crown and resin-based composite of two surfaces, and pay more for the resin-based composite of three surfaces and resin-based composite of four or more surfaces. You say that you were not advised that the treating provider was not in-network. The Plan denied your request. The Plan says the re-cement or re-bond crown is not a covered benefit. The Plan also says that these services were rendered by an OON provider, and your fillings benefit had been exhausted.

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, re-cement or re-bond crown is not among those covered under this benefit. The Plan contract clearly states that restorations (fillings) are limited to two procedures per calendar year. The record shows that you received three resin-based composites on September 3, 2020, two of which were covered by the Plan at the OON benefit rate, and your restorations benefit had been exhausted. You are also responsible for the difference between the billed amount and allowed amount for services rendered OON. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown and resin-based composite of two surfaces, or pay more for the resin-based composite of three surfaces and resin-based composite of four or more surfaces provided on September 3, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup services.

You asked the Plan to pre-approve core buildup services. 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 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. The Plan covers core buildup services when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. Review of the file shows that this requested service is only covered when performed together with a crown. The request is not being made to be performed together with a crown. Based on this information, we decided that the Plan's rules for coverage of core buildup services have not been met. Therefore, we decided that the Plan does not have to pre-approve core buildup services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the routine Electrocardiogram (EKG) with at least 12 leads; with interpretation and report (93000) and specialist office visit (99204) provided October 13, 2020.

You asked the Plan to waive the copayment for the EKG provided at a specialist office visit. You say that you should not be charged the copayment. The Plan denied your request. The Plan says the copayment was applied 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 $40 copayment for provider and professional services provided at a specialist's office. 

You have been asked to pay a $40 copayment for the EKG provided at a specialist office visit. This service 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 the routine Electrocardiogram (EKG) with at least 12 leads; with interpretation and report (93000) and specialist office visit (99204) provided October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs while in observation status from April 29, 2020, to April 30, 2020.
You asked the Plan to pay for the self-administered drugs. You say that the Plan should pay this claim. The Plan denied your request. The Plan says self-administered drugs are not covered while under observation care.
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 pay for the self-administered drugs while in observation status from April 29, 2020, to April 30, 2020.
Benefits for the self-administered drugs 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 provide acute inpatient hospital care for knee surgery.

You asked the Plan to provide acute inpatient hospital care. You say that based on the enrollee's medical issue and age the surgery should be at the inpatient level. The Plan denied your request. The Plan says criteria is not met for inpatient level of care for total knee replacement surgery.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 provide acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for an inpatient admission is met in this case. Our physician reviewer found there is no evidence of unstable chronic medical conditions that would require a determination of in-patient admission before the surgery. The enrollee can be managed in an observation status and then converted to inpatient should the need arise. Therefore, pre-operative in-patient determination cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to provide acute inpatient hospital care for knee surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the clean-up outpatient procedure provided on August 27, 2020.

You asked the Plan to waive the copayment for the third outpatient procedure. You say that this was a clean-up procedure so you would like the copayment waived. The Plan denied your request. The Plan says you have a copayment of $300 for each outpatient surgery or procedure.

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 $300 copayment for each Medicare covered outpatient surgery or procedure for Outpatient Surgery. 

You have been asked to pay a $300 copayment for the third procedure. The third outpatient procedure 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 clean-up outpatient procedure provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a prefabricated right-knee orthosis (L1833) and a suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that the enrollee is using the item with benefit. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered for enrollees who have had recent injury to or a surgical procedure on the knee(s), or for enrollees who are ambulatory and have knee instability due to a specified condition. Knee instability must be documented by examination of the beneficiary and objective description of joint laxity.

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 a knee orthosis and suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in bilateral knees. 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. There is insufficient documentation of an examination 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 a knee orthosis have not been met. The requested suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a prefabricated right-knee orthosis (L1833) and a suspension sleeve (L2397).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter.

You asked the Plan to pay for insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (33210). You say that the Plan should pay this claim. The Plan denied your request. The Plan says 33210 cannot be billed with 93458.

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, we have confirmed that code 33210 insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter has a bundled relationship with catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed code 93458, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says there is no claim in the enrollee history from the prescribing provider.

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 lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis was not medically necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three crowns (D2740 x3) and three core buildups, including any pins when required (D2950 x3).

You asked the Plan to pre-approve the crowns and core buildups. You say that you need these services. The Plan denied your request. The Plan says these 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. Therefore, we decided that the Plan does not have to pre-approve three crowns (D2740 x3) and three core buildups, including any pins when required (D2950 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zoster (Shingles) vaccine provided on September 29, 2020.

You asked the Plan to pay for Shingles vaccine. You say that you are on a fixed income and were not advised that there would be a charge for this. The Plan denied your request. The Plan says the denial of payment for this immunization is correct, because this vaccine is not covered by Medicare Part B and the Plan does not administer your Medicare Part D benefits.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Shingles vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to Shingles vaccine. Therefore, we decided that the Plan does not have to pay for a Zoster (Shingles) vaccine provided on September 29, 2020.

Benefits for Shingles vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 10, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider on October 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laparoscopic removal of the adnexal structures (58661).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a diagnosis of persistent pelvic pain and ovarian cysts. Her pain is increasing. The documented physical examination does not reveal a palpable mass. An ultrasound demonstrated a simple singular ovarian cyst of approximately 1 cm compared to three cysts previously and two simple left ovarian cysts smaller than the previous 1.35 cm and 0.8 cm noted cysts. No adnexal masses were seen. The record also indicates that the enrollee had mesenteric ischemia due to celiac artery stenosis and underwent an angioplasty and stenting as she had to diffuse abdominal complaints. The request is to perform bilateral salpingo-ophorectomy. 

At issue is whether laparoscopic removal of adnexal structures are a covered service under Medicare rules. In the absence of a national or local coverage determination, medically necessary and reasonable services are defined by the Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k). UpToDate indicates that symptoms alone are not typically an indication for surgery in a patient with a mass with an intermediate-or low-risk appearance. 

In this case, the symptoms are moderate, there is no family history of ovarian cancer and no apparent risk factors. The size of the cysts place them in the low risk category. Based upon the documentation provided, the requested procedure cannot be recommended under Medicare rules.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the laparoscopic removal of the adnexal structures (58661).