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

We decided that the Plan does not have to pay for lab services (81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. 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 81401, 81403, 81404, 81405, 81406, 81407, 81408, and 81479 are not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service detailed in the record (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator, any type (L8679).
You asked the Plan to pre-approve an auricular stimulator. You say that this device is necessary to treat your pain. The Plan denied your request. The Plan says this device is statutorily non-covered.
The Plan must follow Medicare rules. Medicare rules say that an auricular peripheral nerve stimulator will be denied as non-covered. We looked at the file and Medicare rules. Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator, any type (L8679) are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of an auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator, any type (L8679).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on March 24, 2021.

You asked the Plan to waive the copayment for the colonoscopy. You say that this was a screening colonoscopy, and nothing was found this time. You say you thought this would be covered as a preventive screening. The Plan denied your request. The Plan says you have been asked to pay 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 $225 copayment for each outpatient surgery and/or services at an ambulatory center or outpatient hospital facility.

You have been asked to pay a $225 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the admitting diagnosis was a history of colon polyps which makes the colonoscopy diagnostic in nature.

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 colonoscopy provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography image (D0380) provided
on April 12, 2021.
You asked the Plan to pay for a cone beam computed tomography image. You say that you want the Plan to
pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone
beam computed tomography image (D0380) provided on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on April 1, 2021, by an out-of-
network provider. 
 
You asked the Plan to pay for the wound care services. You say that medically necessary services were 
provided. The Plan denied your request. The Plan says prior authorization was not requested for the out-of-
network services. 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 wound care services provided on April 1, 2021, by an out-of-
network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this requested procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex procedure is experimental. More research is needed to show safety and efficacy of the 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an interim partial denture (D5820) provided January 7, 2021.
You asked the Plan to pay for the partial denture. You say that the partial denture was medically necessary. The Plan denied your request. The Plan says the item provided is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an interim partial denture (D5820) provided January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth services provided on January 
13, 2021. 
 
You asked the Plan to waive the copayment for the telehealth services with a specialty care physician. You say 
that you did not know there was a charge for virtual visits. The Plan denied your request. The Plan says you 
were charged the copayment 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 Physician Services, Specialty Care Physician.  
 
You have been asked to pay a $34.89 copayment for the televisit with a specialty care physician. The televisit 
with a specialty care physician falls within the Physician Services, Specialty Care Physician benefit category. 
The Medicare allowed amount for this service was less than your copayment which is why your copayment is 
less than the required amount. 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 telehealth services 
provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen equipment (E1399) provided December 30, 2020.

You asked the Plan to pay for the oxygen equipment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the benefit for this service is included in the payment for another service.

The Plan must follow Medicare rules. Medicare rules say that replacement of essential accessories will only be separately payable if the enrollee owns or is purchasing durable medical equipment.

We looked at the file and Medicare rules. In this case, the enrollee is renting and not purchasing the equipment. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen equipment (E1399) provided December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided December 2, 2020.
You asked the Plan to pay for the ambulance response. You say that another ambulance came later in the day and you were transported. The Plan denied your request. The Plan says ambulance service is only a covered benefit when a transport occurs.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on December 2, 2020. The record shows that at the time of the ambulance response you stated you wanted a health check only and did not want to go to the Emergency Room. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided December 2, 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 you meet criteria for IRF. The Plan denied your request. The Plan says the medical record does not show that it is necessary to treat your medical condition at the IRF level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 8, 2020, through July 15, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be responsible for these charges because it should be considered one hospital stay. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment per day for days 1-6, and a $0 copayment per day for additional hospital days for inpatient hospital care. The enrollee has been asked to pay a $1950 copayment for inpatient hospital care. The services at issue fall within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 8, 2020, through July 15, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GENVISC 850 (J7320).

You asked the Plan to pre-approve GENVISC 850. You say that the service is medically necessary. The Plan denied your request. The Plan says the member has not tried and failed the preferred step therapy drug.

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 GENVISC 850. Our reviewer says that the drug is not medically necessary. Our physician reviewer found a trial of drug Monovisc is required before the Plan will approve the requested drug. In this case, the patient has not tried and failed the required drug and there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GENVISC 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve GENVISC 850 (J7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on August 25, 2020 and March 2, 2021.
You asked the Plan to pay for the dental services. You say that you had extensive dental work done with this doctor and was not aware you needed to use a network provider. You say that the denial should be reconsidered. The Plan denied your request. The Plan says the Plan does not cover services from a provider who is not in-network. edicare 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services provided on August 25, 2020 and March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic items provided from April 9, 2021, to April 12, 2021.
You asked the Plan to pay for orthotic items. You say that the enrollee requested services utilizing access to telemedicine in order to address COVID-19 concerns. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the record includes insufficient documentation to corroborate the items billed so the Plan can confirm Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required for DMEPOS items to determine the amounts due to the supplier.
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of delivery for the specific items billed on this claim. Based on this information, we decided that Medicare rules for coverage of orthotic items have not been met. Therefore, we decided that the Plan does not have to pay for orthotic items provided from April 9, 2021, to April 12, 2021
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 IRF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have 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 in the Medicare rules section.
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 that the patient was admitted for surgical treatment of chronic thrombotic
pulmonary hypertension. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, here is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on January 30, 2020.
You asked the Plan to pay for genetic testing. You say that the results of this testing were needed by the ordering physician in a timely manner so that they could make an informed decision on the enrollee's course of treatment. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing is considered to be investigational.
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. 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 January 30, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve a therapeutic CGM. You say that this request is medically necessary for the enrollee's diabetes. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device and accessory to be provided by an OON provider.
You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that this device is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide this equipment.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and accessory to be provided by an OON provider.