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

We decided that the Plan does not have to pre-approve Neoxflo/clarixflo (Q4155).
You asked the Plan to pre-approve Neoxflo/clarixflo. You say that the drug is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Neoxflo/clarixflo in the setting of wound care has not been demonstrated in the peer-reviewed literature.
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 Neoxflo/clarixflo. Our reviewer says that the drug is not medically necessary. Our physician reviewer found the documentation does not support that the Neoxflo/clarixflo (Q4155) is safe and effective for the intended use. The clinical value and effectiveness of Neoxflo/clarixflo (Cryo-preserved human amniotic membrane injection) in the setting of wound care has not been demonstrated in the peer-reviewed literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neoxflo/clarixflo have not been met. Specifically, the documentation does not support that this drug is safe or effective for your use. This means that it is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve Neoxflo/clarixflo (Q4155).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 16, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Per Medicare payment guidelines, for dates of service on or after October 1, 2015, claim forms should be coded with ICD-10 codes. The claims submitted in this case have ICD-9 codes. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 16, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on July 9, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with medical records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
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 for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on July 9, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Medicare says providers should use the diagnosis code for billing that
describes the patient's diagnosis, symptom, complaint, condition or problem to the highest level of specificity.
In this case, the records do not support the billing of diagnosis code M25.559. There is a more appropriate
diagnosis code for the services provided. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of
intraoral x-rays provided on March 9, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that you were given misinformation and were told the treating provider is out-of-network. The Plan denied
your request. The Plan says benefits for these services have been satisfied and the frequency limitations have
been exceeded.
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, comprehensive oral evaluation is
limited to one procedure code every three years, and full mouth or panoramic x-rays are limited to one
procedure code every five years. The record shows that you received a comprehensive oral evaluation and
panoramic x-ray on October 20, 2020, and your comprehensive oral evaluation and full mouth or panoramic xrays
benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation and complete series of intraoral x-rays provided on March 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided February 13, 2021 to February 14, 2021.
You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services must be billed separately as outpatient services.
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 find that the emergency room services are not supported in the medical record. Specifically, the services were billed with inpatient services. Emergency room services must be billed separately as an outpatient service. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided February 13, 2021 to February 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and cleaning (D1110) provided on February 18, 2021, by an out-of-network provider.
You asked the Plan to pay for the evaluation and cleaning. You say that your contract says there is no copay for dental exams and cleanings. The Plan has paid for these services in full before, so you do not understand why you are being charged. The Plan denied your request. The Plan says the provider in this case is out-of-network. If you use an out-of-network provider, you may be billed for any amount that is greater than the Plan's payment.
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's contract states that the Plan will pay up to a certain amount for each service. If you choose to see an out-of-network provider, you may be billed for any amount greater than what the Plan pays, even for services listed as a $0 copayment.
The Provider billed the Plan $149 for the evaluation and the dental cleaning. The Plan's maximum allowed fee for both services amounts to $60. The Plan paid the full allowed amount, as these services are listed in the contract with a $0 copayment. In-network providers have agreed to be paid the Plan's fee and not bill enrollees for any other amount; however, out-of-network dental providers do not have this agreement and are allowed to bill you for the remaining charges up to their billed amount. In this case, an out-of-network provider was used, and you have been billed $89. ($149 full bill - $60 plan payment = $89 remaining). This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay an additional amount or waive the cost-sharing for the periodic oral evaluation (D0120) and cleaning (D1110) provided on February 18, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor and supplies (K0553, K0554) provided January 8, 2021.
You asked the Plan to pay for the therapeutic continuous glucose monitor and supplies. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the member has a separate primary insurance plan.
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 has directed the provider to reach out to the specified primary insurer in their decision letter. As the secondary insurer, the Plan cannot be held responsible for the therapeutic continuous glucose monitor and supplies until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor and supplies (K0553, K0554) provided January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 23, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that laboratories 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 provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical access to an implant body (second stage implant surgery) (D6011), implant /abutment supported removable denture for edentulous arch - mandibular (D6111), sinus augmentation with bone or bone substitutes via a lateral open approach (D7951), and bone replacement graft for ridge preservation - per site (D7953)
You asked the Plan to pre-approve a surgical access to an implant body, implant /abutment supported removable denture, sinus augmentation, and bone replacement graft. You say that the services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your dental benefits. The implant /abutment supported removable denture may sometimes be covered by the Plan when medically necessary, however, since the implant is denied, the implant supported denture is denied as well.
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 a surgical access to an implant body (second stage implant surgery) (D6011), implant /abutment supported removable denture for edentulous arch - mandibular (D6111), sinus augmentation with bone or bone substitutes via a lateral open approach (D7951), and bone replacement graft for ridge preservation - per site (D7953)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography and tomosynthesis interpretation provided on February 12, 2021, billed with codes 77067-26 and 77063-26.
You asked the Plan to pay for the mammogram/tomosynthesis interpretation. You say that this should be paid. The Plan denied your request. The Plan says payment was approved for the breast ultrasound. However, the codes 77063 and 77067 are duplicates of previously paid services.
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims or line items will be denied.
In this case, we find that payment was already made for these services per a remittance dated February 24, 2021. As there is no evidence that this service was provided more than once, the denial of payment is supported. Therefore, we decided that the Plan does not have to pay for the screening mammography and tomosynthesis interpretation provided on February 12, 2021, billed with codes 77067-26 and 77063-26.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided April 8, 2020, to April 22,
2020.
You asked the Plan to pay for the inpatient hospital services. You say that you would like this claim
reprocesses and approved for payment. The Plan denied your request. The Plan says that this claim was not
billed in accordance with Medicare guidelines.
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.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, the denial appears to reference the hospital at issue being an Indian
Health Service facility. Based on our research, this is not correct. There is no apparent problem with the claim
at issue and we have not received a valid citation to understand why this claim is not paying. Therefore, we
decided that the Plan has to pay for the inpatient hospital services provided April 8, 2020, to April 22, 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 pay for the initial hospital care represented by code 99223 provided
on January 5, 2021.
You asked the Plan to pay for code 99223. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered.
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 has requested the
provider to send the claim to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for code 99223 until the primary insurer has denied the claim for these services. Therefore, we decided that the
Plan does not have to pay for the initial hospital care represented by code 99223 provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397), provided on November 10, 2020, by an out-of-network provider.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items were medically necessary. The Plan denied your request. The Plan says the DME was provided without a face to face evaluation, physical examination or imaging demonstrating medical necessity. The enrollee was contacted through an unsolicited outreach telephone call.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397), provided on November 10, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) scan provided on March 10, 2021.
You asked the Plan to pay for the PET/CT scan. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file, the Plan's contract and Medicare rules. We find that the PET/CT scan is not supported as
billed. Specifically, this PET/CT scan was not billed with an appropriate diagnosis code per Medicare
guidelines. Therefore, we decided that the Plan does not have to pay for the Positron emission tomography
(PET) with concurrently acquired computed tomography (CT) scan provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on November 10, 2020.
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician regarded this testing as a medically necessary and valuable tool for treatment of the enrollee. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because predictive screening testing is not a Medicare 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. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided on November 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve the Intracept procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven the effectiveness of the requested procedure for your condition.

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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for the treatment of low back pain. More research is needed to show safety and efficacy of the intracept procedure. 

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. The Plan denied your request. The Plan says items that are used for a preventative service or function are excluded from coverage.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).