Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 97140) provided on February
7, 2020.
You asked the Plan to pay for the services. You say that the services are necessary. The Plan denied your
request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the chiropractic services (CPT 97140) provided on February 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93005) provided on July 26, 2019 by an out of network provider.
You asked the Plan to pay for an electrocardiogram. You say that authorization is not needed for this service. The Plan denied your request. The Plan says out-of-network services that are not urgent or emergent require 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 has network providers available who can provide 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 an electrocardiogram (93005) provided on July 26, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CTA scan of the abdomen and pelvis for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has had a small abdominal aortic aneurysm measuring 3.5 cm in diameter last measured by CTA in 2018 and has no symptoms such as abdominal pain, claudication etc. The guidelines call for aneurysm surveillance every 3 years unless there are clinical symptoms to imply expansion etc and none are documented in the submitted records.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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approve CTA scan of the abdomen and pelvis for the enrollee.
Appeal type: Surgery
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 January 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 has network providers
available who can provide 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 January 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, and subsequent hospital care
provided from August 29, 2019 to August 30, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that the enrollee was discharged from
hospice on August 28, 2019, one day prior to the visits. The Plan denied your request. The Plan says that upon
discharge or revocation, fee-for-service Medicare continues to cover the enrollee through the end of the month
when the enrollee revokes or is discharged from hospice alive. The Plan also says that at the end of the month
following revocation or discharge, all billing and coverage revert back to the managed care plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The Physician ended Medicare Hospice benefits on August 28, 2019. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care, and
subsequent hospital care provided from August 29, 2019 to August 30, 2019.
Appeal type: Lab
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 February 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 has network providers
available who can provide 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 February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 10, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 laboratory services provided on January 10, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the right knee. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not support that the required drugs would be less effective or contraindicated; therefore, Hyalgan is not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a CT Scan of the neck and spine (72125) CT Scan of the chest and spine (72128) and CT Scan of the lumbar spine (72131) provided on October 8, 2018.
You asked the Plan to pay for the CT Scans. You say that you billed this claim globally for the technical and professional component because the Provider owns the equipment being used. The Plan denied your request. The Plan says that the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician.
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 CPT code 72125, 72128 and 72131 is supported in the record. Specifically, the provider billed globally for services that are split into PC and TC components. The record shows that the PC and the TC were furnished by the same physician within the same Medicare Physician Fee Schedule Payment locality. This means that Medicare rules for billing globally for services that are split into PC and TC components have been met. Therefore, we decided that the Plan has to pay for a CT Scan of the neck and spine (72125) CT Scan of the chest and spine (72128) and CT Scan of the lumbar spine (72131) provided on October 8, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Combigan.
You asked the Plan to pre-approve Combigan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 pre-approve Combigan.
Benefits for Combigan 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF System (33289, C2624).
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 CardioMEMS HF System have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF System (33289, C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram coded 93010 and the emergency department visit services coded 99285 provided on December 28,2019.You asked the Plan to pay for the electrocardiogram and the emergency department visit services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed without a valid primary diagnosis code.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 CPT codes 93010 and 99285 are not supported in the medical record. Specifically, these codes were billed with a diagnosis code of G46.7 (other lacunar syndromes.) Diagnosis code G46.7 is a secondary diagnosis. A secondary diagnosis cannot be used as the primary, first-listed or principal diagnosis. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram and the emergency department visit services have not been met.Therefore, we decided that the Plan does not have to pay for the electrocardiogram coded 93010 and the emergency department visit services coded 99285 provided on December 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forportable x-ray services (HCPCS R0070) provided to the enrollee on January 24, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis code has a professional component (PC)/technical component (TC) indicator of 3.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services withthe appropriate code.In this case, the CPT Code Manual definition of HCPCS code R0070 is "Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the services provided to the enrollee were provided via a mobile clinic. As such, the point of service should be a mobile clinic (15), not a skilled nursing facility (31). As the equipment remains on the mobile clinic, it is not transported to the enrollee. Therefore, the billing of R0070 is not supported.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forportable x-ray services (HCPCS R0070) provided to the enrollee on January 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ultrasound provided on March 18, 2020.
You asked the Plan to waive the deductible for the ultrasound. You say that you should not be responsible for
paying this amount. 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. Your
contract with the Plan says that there is a $750 deductible that applies towards basic imaging service (e.g.,
general x-rays or ultrasound).
The ultrasound you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and
therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing
in the contract that there is a $750 deductible that applies towards each basic imaging service (e.g., general xrays
or ultrasound). This cost sharing is a contractual obligation that had not been met at the time the
ultrasound was received on March 18, 2020. Therefore, we decided that the Plan does not have to waive the
deductible for the ultrasound provided on March 18, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea magnetic resonance imaging (MRI) of the breast (77049).You asked the Plan to pre-approvean MRI of the breast. You say that the service is necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that breast MRIs are covered when specific criteria is met.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 an MRI of the breast. Our reviewer says that the service is medically necessary. Our physician reviewer found this enrollee has a new clinical finding which may be related to evolving radiation fibrosis however recurrent tumor is not ruled out. Prior MRI revealed probable changes related to radiation but follow-up was suggested and currently there has been a change on the clinical exam. MRI is the most sensitive means with which to evaluate the post op/radiation treated breast and together with the abnormal physical exam criteria are met to provide a valid indication for MRI.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the breast have been met.Therefore, we decided that the Plan has to pre-approvea magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99203), x-ray exam of the spine (72100), extra-spinal manipulative treatment (98943), mechanical traction therapy (97012), and the electrical stimulation (G0283) provided on January 14, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says these services are not a covered benefit under the enrollee's contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services provided do not meet Medicare criteria for coverage of chiropractic services and therefore, are not covered under the Plan contract.Therefore, we decided that the Plan does not have to pay forthe office visit (99203), x-ray exam of the spine (72100), extra-spinal manipulative treatment (98943), mechanical traction therapy (97012), and the electrical stimulation (G0283) provided on January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly moderate assist (x 2 persons) for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub transfer bench(E0245).You asked the Plan to pre-approve a tub transfer bench. You say that a tub transfer bench is necessary to shower as you have weakness in your legs.The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy.The Plan must follow Medicare rules. Medicare rules say that hygienic equipment is not covered as it is not primarily medical in nature. While a tub transfer bench may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a tub transfer bench (E0245).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 6, 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 physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted 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 drug testing rendered on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extraction provided on January 9, 2018.
You asked the Plan to pay for the extraction. The Plan denied your request. The Plan says that this is not covered under the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the tooth extraction provided on January 9, 2018.