Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantable wireless pulmonary artery pressure
monitoring (C2624).
You asked the Plan to pre-approve the implantable wireless pulmonary artery pressure monitoring. You say
that the enrollee meets the criteria for invasive pulmonary artery pressure monitoring using CardioMEMS
system to reduce risk for future admissions for heart failure exacerbation. The Plan denied your request. The
Plan says this device is investigational and experimental as there is not enough medical evidence that shows
use of the device is helpful, safe and improves the quality of life.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the implantable wireless pulmonary artery pressure monitoring have not been met. Therefore, we
decided that the Plan does not have to pre-approve the implantable wireless pulmonary artery pressure
monitoring (C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 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 skilled nursing services provided on December 25, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve routine transportation trips. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered
benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance.
The Plan follows the same rule.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Medicare rules for coverage of routine transportation trips have not been met. Therefore, we decided
that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (15004, 28124, 28202, 28210, and 28313)
provided on January 30, 2019.
You asked the Plan to pay for surgical services. You say that these procedures are listed in the operative report.
The Plan denied your request. The Plan says the submitted records do not include a detailed procedure note.
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 15004, 28124, 28202, 28210, and 28313 are not supported in the medical record.
Specifically, the detailed operative report submitted is for a different date of service. Without an operative
report for the date of service at issue, these services cannot be verified. Based on this information, we decided
that Medicare rules for coverage of surgical services have not been met. Therefore, we decided that the Plan
does not have to pay for surgical services (15004, 28124, 28202, 28210, and 28313) provided on January 30,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants.
You asked the Plan to pre-approve the implant. You say that this is medically necessary, and you disagree with the denial. The Plan denied your request. The Plan says this is not a covered benefit under the plan.
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 dental implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin graft provided on December 26, 2019 and January 2, 2020.
You asked the Plan to waive the copayment for the skin grafts. You say that you normally have an office visit copayment for the procedure. The Plan denied your request. The Plan says the copayment 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 $100 per day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $100 copayment for each skin graft. The total amount you owe is $200 ($100/graft x 2 grafts = $200). The skin grafts fall within the "Outpatient hospital services" benefit category. The records show that the skin grafts were billed by the hospital. 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 skin graft provided on December 26, 2019 and January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the UV lenses, anti-reflective coating, progressive lenses, and polycarbonate lenses rendered on January 22, 2020.
You asked the Plan to pay for these services. You say that you were told that you needed the services for your vision. The Plan denied your request. The Plan says the items are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of standard lenses and frames OR contact lenses every two years.
We looked at the file and the Plan's rules. The file shows that you received UV lenses, anti-reflective coating, progressive lenses, and polycarbonate lenses. These services are not considered standard lenses and are not covered by Medicare or your supplemental vision benefit. Therefore, we decided that the Plan does not have to pay for the UV lenses, anti-reflective coating, progressive lenses, and polycarbonate lenses rendered on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on January 15, 2020.You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not separately payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour.We find that CPT code 99190 is not supported in the medical record. Specifically, this services were provided while the enrollee was inpatient. Payment for these services would be included in the Part A DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met.Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical mask, per 20 (A4928x3). You asked the Plan to pre-approve the surgical mask. You say that you feel that this should be covered because it is an official law. You have asthma and uses a CPAP and you need the mask to help you stay healthy. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve surgical mask, per 20 (A4928x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture and mandibular partial
denture.
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that
your previous denture does not fit correctly. You also say that you have tried to get it fixed but it still hurts your
lower jaw. The Plan denied your request. The Plan says these services exceed the benefit allowance.
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, dentures are limited to one set every 5
years. The record shows that you received a maxillary partial denture and mandibular partial denture on
September 19, 2019 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does
not have to pre-approve a maxillary partial denture and mandibular partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1845) provided to the enrollee on July 16, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Healthcare Common Procedure Coding System (HCPCS) code L1845 LT KX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order for the billed supply; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1845) provided to the enrollee on July 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from November 3, 2019 at 5:20pm through November 4, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 inpatient hospital care. Our physician
reviewer found the review indicates that all inpatient care provided after 5:19 pm on November 3, 2019
through 9:28 pm on November 4, 2019 was not needed at the nonplan facility. The enrollee was
hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility. The post stabilization care services 5:19 pm on November 3, 2019 through 9:28 pm on November 4, 2019 were not
medically necessary and reasonable. The review has determined that the treating physician did not document
(in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan
does not have to pay for inpatient hospital care provided to the enrollee
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve continued use of CPAP for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the enrollee was complaint for thirty days. The Plan denied your request. The Plan says that the enrollee does not show compliance.
The Plan must follow Medicare rules. Medicare rules say that CPAP therapy can be continued if there is objective evidence of adherence to therapy. 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee initially received the CPAP on October 23, 2019. A face to face follow up visit 1/22/20 indicates that the enrollee's symptoms of excessive daytime sleepiness had resolved with CPAP. Objective evidence of compliance was demonstrated for the 30 day period from October 23, 2019 - November 21, 2019; the report indicates use of the CPAP device for 4 or more hours for 21 of 30 nights (70%). The enrollee has demonstrated adherence to therapy. The documentation supports that the requested extension of CPAP services - E0601 is 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 services have been met. Therefore, we decided that the Plan has to pre-approve continued use of CPAP for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the vertebral corpectomy services coded 63081 and 63082 and the insertion of intervertebral biomechanical device services coded 22854 provided on October 11, 2019.
You asked the Plan to pay for the vertebral corpectomy services and the insertion of intervertebral biomechanical device services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 63081, 22854, and 63082 are not supported in the medical record. Specifically, the operative report did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), using an anterior approach with decompression of spinal cord and/or nerve root(s), for a single cervical segment; therefore, code 63081 cannot be verified.
The operative report did not include documentation of an insertion of intervertebral biomechanical device(s) (synthetic cage, mesh), with integral anterior instrumentation for device anchoring (screws, flanges) when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, for each contiguous defect (listed separately in addition to code for primary procedure); therefore, code 22854 cannot be verified.
The operative report did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), using an anterior approach with decompression of spinal cord and/or nerve root(s), for each additional cervical segment (listed separately in addition to code for primary procedure); therefore, code 63082 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the vertebral corpectomy services and the insertion of intervertebral biomechanical device services have not been met. Therefore, we decided that the Plan does not have to pay for the vertebral corpectomy services coded 63081 and 63082 and the insertion of intervertebral biomechanical device services coded 22854 provided on October 11, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the oncology assay (4k score testing) provided on November 22, 2019.
You asked the Plan to pay for the 4k score testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.
Review of the file shows that the plan uses Local Coverage Determination, LCD L37798 to support their denial. However, LCD L37798 is not valid for Medicare Part B for the state of NJ. Therefore, this LCD is not the valid jurisdiction and we cannot use LCD L37798 to substantiate our decision. 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 4k score testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a prostate specific antigen (PSA) of 15.33. The enrollee is between the ages of 40 and 80. The enrollee has had no previous prostate biopsy. The enrollee has elevated PSA. The enrollee has no high risk feature. Therefore, the enrollee met criteria for the services rendered. 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 4k score testing have been met. Therefore, we decided that the Plan has to pay for the oncology assay (4k score testing) provided on November 22, 2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on January 22, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you've never had a bill like this before. You say that the copayment is high for a 5 second test. The Plan denied your request. The Plan says the copayment 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 $325 per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $325 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. No medical records were received to support the diagnosis on the submitted order; therefore, the bill code cannot be supported. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on December 23, 2019.