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

We decided that the Plan does not have to waive the copayment for laboratory services (85025, 85652, 80048, 36415).

You asked the Plan to waive the copayment for laboratory services. You say that you have already paid for this service. The Plan denied your request. The Plan says this processed 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 $35 copayment for laboratory services provided at a specialist laboratory.

You have been asked to pay a $24.95 copayment for laboratory services because the allowed amount is less than $35. 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 laboratory services (85025, 85652, 80048, 36415).

Your complaint about how the provider is billing is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure (97112) and manual therapy 
techniques (97140) provided on September 3, 2020. 
 
You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not include 
the amount of time spent rendering the therapy services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 97112 and 97140 
 is not supported in the record. Specifically, the record does not include the amount of time spent rendering the 
billed services. Based on this information, we decided that Medicare rules for coverage of the therapy services 
have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure 
(97112) and manual therapy techniques (97140) provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140).

You asked the Plan to pay for the problem focused limited oral evaluation. You say that the provider's receptionist contacted the Plan and was advised that this service would be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. The Plan also says there were no calls from you or the provider prior to the service being rendered.

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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140), and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq, 50 mg tablet.

You asked the Plan to pre-approve Myrbetriq. You say that the enrollee started taking this medication in 2017. You say that changing the enrollee's medication at this time would jeopardize deteriorating his condition. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 Myrbetriq, 50 mg tablet.

Benefits for Myrbetriq 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 DecisionDx-Melanoma testing.

You asked the Plan to pay for the DecisionDx-Melanoma testing. You say that you would like reconsideration because this testing was ordered by the physician to inform the treatment decisions. The Plan denied your request. The Plan says this is not a Medicare covered benefit.

The Plan follows Medicare rules. Medicare rules say that 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 pay for the DecisionDx-Melanoma testing. Our reviewer says that there are no peer-reviewed published studies confirming the hypothesis that DecisionDx-Melanoma signature may be an independent predictor of metastasis risk. Our physician reviewer found this testing is not medically reasonable and 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 DecisionDx-Melanoma testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-Melanoma testing
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound and office visit.

You asked the Plan to pay for the ultrasound and office visit. The Plan denied your request. The Plan says that it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you may be required to use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers. If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Your provider would need to obtain an authorization from the plan for this 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 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 an ultrasound and office visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for residential treatment.

You asked the Plan to pay for the residential treatment. 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 residential treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 29, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 physician's services provided on October 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the autograft (15100 and 15101), wound prep (15002 and 15003) and application of skin substitute (15273 and 15274).

You asked the Plan to pay for the autograft, wound prep and application of a skin substitute. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 15100, 15002, 15101, 15273, 15274 and 15003 are not supported in the medical record. Specifically, the record submitted does not include any clinical information or medical records to confirm that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the autograft, wound prep and application of a skin substitute have not been met. Therefore, we decided that the Plan does not have to pay for the autograft (15100 and 15101), wound prep (15002 and 15003) and application of skin substitute (15273 and 15274).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this 
test was a medically necessary diagnostic evaluation. The Plan denied your request. The Plan says the 
diagnosis code submitted does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the record does not include a physician 
order, lab results or medical records to verify if Medicare coverage criteria have been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable 
harness (E2313) and electronic connection (E2311), transfer handles and gel pads (both accessories coded 
K0108), and a seat elevator (E2300). 
 
You asked the Plan to pre-approve an expandable controller with expandable harness and electronic 
connection, transfer handles and gel pads, and a seat elevator. You say that the enrollee has a medical need for 
customized equipment. The Plan denied your request. The Plan says these items have no medical purpose or 
need. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
Regarding the request for an expandable controller with expandable harness and electronic connection: 
 
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 expandable controller with 
expandable harness and electronic connection. Our reviewer says that the requested items do not serve a 
medical purpose. Our physician reviewer found that, based on the medical records provided, there is no 
documentation that there a medical need to control these power options for the wheelchair via a joystick. 
Records indicate that the enrollee's upper limb strength and function are adequate to control these power 
options using the device's specific switch controls. Records indicate the enrollee dresses by themselves and 
drives a van with hand controls. 
 
Regarding the request for transfer handles and gel pads: 
 
We also 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 transfer handles and gel pads. Our 
reviewer says that the requested items do not serve a medical purpose. Our physician reviewer found that, 
based on the medical records provided, there is no documentation that the transfer handles or gel pads are 
medically necessary or are serving a primarily medical purpose. 
 
Regarding the request for a seat elevator: 
 
The rules say that a power seat elevation feature are non-covered because they are not primarily medical in 
nature. 
 
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 requested items have not been met. The items at issue in this appeal do not 
serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection 
(E2311), transfer handles and gel pads (both accessories coded K0108), and a seat elevator (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 28, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 physician's services provided on August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery rendered from 
October 5, 2020 to October 19, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services were not performed in 
a hospital. 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 $250 
copayment per visit for in-network Medicare-covered ambulatory surgical center and outpatient hospital 
facility visits.  
 
Review of the file shows that you received outpatient surgical services on October 5, 2020 to October 19, 2020. 
You have been asked to pay a $250 copayment for these services. The Plan confirmed that the provider?s office 
is located in a hospital-based clinic. These services fall within the in-network Medicare-covered ambulatory 
surgical center and outpatient hospital facility 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 outpatient surgery rendered from October 5, 2020 to October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the Botox injections are medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that there are a variety of indications which Botox 
may be used for. 
 
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 Botox. Our reviewer says that this 
service does not meet the criteria listed in the LCD. Our physician reviewer found the LCD does not support 
the use of Botox for the enrollee's specific medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox injections (J0585).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of erupted tooth or exposed root (D7140) 
provided on October 13, 2020. 
 
You asked the Plan to pay for the extraction of erupted tooth or exposed root. You say that you would like the 
plan to cover the service you received. The Plan denied your request. The Plan says this service is not covered 
under your supplemental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction of erupted tooth or exposed root (D7140) provided on October 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care.

You asked the Plan to pay for inpatient care. You say that the service was medically necessary. The Plan denied your request. The Plan says the member was in hospice.

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 enrollee ended Medicare Hospice benefits on March 7, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve superion interspinous spacer.

You asked the Plan to pre-approve superion interspinous spacer. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for spinal stenosis lumbar region with neurogenic claudication. Conservative treatment had included medications, chiropractic manipulation, left greater trochanteric bursa injection, epidural steroid injection, and physical therapy. The safety and effectiveness of the Superion Interspinous Spacer has not been studied in patients with the following conditions: axial back pain without leg, buttock, or groin pain; symptomatic lumbar spinal stenosis at more than two levels; prior lumbar spine surgery; significant peripheral neuropathy; acute denervation secondary to radiculopathy; Paget's disease; vertebral metastases; morbid obesity; pregnancy; a fixed motor deficit; angina; active rheumatoid arthritis; peripheral vascular disease; advanced diabetes; or other systemic disease that may affect the patient's ability to walk. Contraindications included scoliosis (Cobb angle > 10 degrees), spinal instability, prior fusion or decompression at the index level, active systemic infection, cauda equina syndrome, and severe osteoporosis. 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. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 9, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 
physician's services. 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 physician's services provided on July 9, 2020.