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

We decided that the Plan does not have to pre-approve F2 gene analysis services.You asked the Plan to pre-approve the F2 gene analysis services. You say that the records provided support the need for the test being requested.The Plan denied your request. The Plan says Medicare rules state that the requested test is non-covered The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare coverage rules state that F2 genetic tests are not considered to be clinically efficacious.Therefore, we decided that the Plan does not have to pre-approveF2 gene analysis services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hip replacement surgery.
You asked the Plan to pre-approve the requested surgery. You say that your leg is in pain and you struggle to get through exercises. The Plan denied your request. The Plan says your body mass index caries significant risk of complications.
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 requested surgery. Our physician reviewer found that your body mass index (BMI) is over 40 and caries significant risk of complications. Therefore, the requested services are not medically reasonable and necessary at this time. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve hip replacement surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 5, 2019
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 the services were rendered by an out-of-network provider without 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 referring provider 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 the laboratory services provided on October 5, 2019
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 it is medically necessary for the enrollee to receive care in an IRF.The Plan denied your request. The Plan says the enrollee does not have critical medical needs requiring daily physician intervention. The Plan says that the enrollee is medically stable for transfer to an alternate 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision in an IRF. The enrollee's current functional level is near her baseline after her skilled nursing facility (SNF) discharge in February of 2020. The enrollee may benefit from and participate in additional physical and occupational therapy but does not require this on an intensive rehabilitation facility therapy program level 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and the incomplete endodontic therapy (D3332) provided on December 12, 2019.You asked the Plan to pay for the dental services. You say that the dentist found that the tooth had a fracture and could not be saved with endodontic therapy. You say that the dentist was not able to complete any further steps. You say that you were advised the tooth needs to be removed and a regular x-ray 3D cone was done.The Plan denied your request. The Plan says the cone beam CT is not a covered service. The Plan also says that the incomplete endodontic therapy is not a covered service.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 cone beam CT is not among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that incomplete dental services are not covered.Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and the incomplete endodontic therapy (D3332) provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on October 22, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care and the ordering physician was not a plan contract provider.
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 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 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 lab services provided to the enrollee on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiation therapy services (77338, 77370, 77300, and 77301) provided on October 17, 2018 to October 26, 2018 by an out of network (OON) provider.
You asked the Plan to pay for radiation therapy services. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 the radiation therapy services (77338, 77370, 77300, and 77301) provided on October 17, 2018 to October 26, 2018 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on January 3, 2019 to April 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you were unaware that you needed a referral for this. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers that could have performed these 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 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 chiropractic services provided on January 3, 2019 to April 2, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns for tooth #'s 4 & 6 and a pontic for tooth
#5.
You asked the Plan to pre-approve the retainer crowns and pontic. You say that these procedures are necessary
for the enrollee's overall dental health. The Plan denied your request. The Plan says the services are not
medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the retainer
crowns and pontic when the services are medically necessary and reasonable.
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 retainer crowns and pontic. Our
reviewer says that the services are not medically necessary. Our physician reviewer found coverage for a fixed
bridge is limited to replacement of a single maxillary anterior tooth or two mandibular anterior teeth when there
are no missing posterior teeth. Our reviewer found that, in this case, tooth #5 is a posterior tooth and there are
other missing maxillary posterior teeth. Our physician reviewer also found that there was no indication that a
removable partial could not be used.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the retainer crowns and pontic have not been met. Therefore, we decided that
the Plan does not have to pre-approve retainer crowns for tooth #'s 4 & 6 and a pontic for tooth #5.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an extremity study (93970) provided on October 15, 2019. You asked the Plan to pay for the extremity study. You say that you supply the equipment and render the reading, therefore you are able to bill globally. The Plan denied your request. The Plan says when a SNF resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component (representing the physician's interpretation of the test results) is a separately billable physician service under Part B. The Plan must follow Medicare rules. Medicare rules say that when an SNF resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component is a separately billable physician service under Part B. We find that CPT code 93970 is not supported in the record. Specifically, the technical component of this service is included in the payment to the facility. CPT code 93970 was not billed with modifier 26 to indicate that this was the professional component. Based on this information, we decided that Medicare rules for coverage of the extremity study have not been met. Therefore, we decided that the Plan does not have to pay for an extremity study (93970) provided on October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on July 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was on hospice when the services were rendered.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on July 11, 2019.
Appeal type: Practitioner Services
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 September 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these 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 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 September 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 1, 2019 through November 8, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and is not valid for Medicare purposes.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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 1, 2019 through November 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered to the enrollee from December 3, 2019 to December 10, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered to the enrollee from December 3, 2019 to December 10, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker check provided on October 28, 2019.You asked the Plan to waive the copayment for the pacemaker check. You say that you were told the copayment would be $0 because a pacemaker is preventive. You say you need to have this appointment but cannot afford it. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, flat film x-rays, and ultrasounds. You have been asked to pay a $20 copayment for the pacemaker check. The pacemaker check falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the pacemaker check is considered a diagnostic test.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 pacemaker check provided on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Verio Strips (A4253).You asked the Plan to pre-approve the One Touch Verio Strips. You say that that test three times a day and your numbers are all over the place. The Plan denied your request. The Plan says you do not have visual impairment requiring a voice meter or insulin pump designed to communicate with this machine.The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.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 One Touch Verio Strips. Our reviewer says that it is not medically reasonable and necessary for you to use the non-preferred brand, One Touch Verio.Our physician reviewer found you do not have a visual impairment requiring a voice monitor, nor do you have an insulin pump, which would require a specific machine to communicate with.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 One Touch Verio Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One Touch Verio Strips (A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens prescription and fitting (92310) purchased January 7, 2020.You asked the Plan to pay for contact lens prescription and fitting. You say that the fitting was a part of the doctors diagnosis and treatment to provide you with improved vision. The contact lens fitting was an integral and essential part of your vision care that day.The Plan denied your request. The Plan says the requested service is not a covered benefit.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 these services when one pair of eyeglasses or contact lenses are covered for people after cataract surgery. No other eyewear is covered unless you are enrolled in Advantage Plus.We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we decided that the Plan's rules for coverage of contact lens prescription and fitting have not been met.Therefore, we decided that the Plan does not have to pay for contact lens prescription and fitting (92310) purchased January 7, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Megestrol AC 20mg tablets.
You asked the Plan to pre-approve the Megestrol tablets. You say that the enrollee needs this as she has hot flashes and difficulty sleeping. The Plan denied your request. The Plan says this self-administered drug cannot be covered by 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 Megestrol AC 20mg tablets.
Benefits for the Megestrol tablets 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye exam (92014) refraction (92015) prescription/fitting of contact lens (92310) annual supply disposable contact lens (S0500) not medically necessary service (S9986) provided October 11, 2019.You asked the Plan to pay for the vision services. You say that the provider insisted that the fitting charge is not a covered benefit and had you pay out of pocket. The fitting charge is clearly covered per the Evidence of Coverage and you request reimbursement.The Plan denied your request. The Plan says the plan does not cover fit and follow ups or when provided out-of-network.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 vision services when provided at a network optical provide.We looked at the file and the Plan's rules. the plan does not cover fit and follow ups or when provided out-of-network. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for eye exam (92014) refraction (92015) prescription/fitting of contact lens (92310) annual supply disposable contact lens (S0500) not medically necessary service (S9986) provided October 11, 2019.