Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Fractional Flow Reserve (FFR) testing.
You asked the Plan to pre-approve FFR testing. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.
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. 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 FFR testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given that he has known calcified moderate coronary artery disease (CAD), a functional assessment of these lesions with this repeat coronary computed tomography angiography (CCTA) is reasonable and medical necessary to assess their clinical significance and the need for further medical therapy or possibly angiography and revascularization. Computed tomography (CT) FFR will provide a standardized assessment of the significance of these known lesions and conforms with the medical necessity and reasonableness criteria for the applicable CMS rule 1862(a) criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of FFR testing have been met. Therefore, we decided that the Plan has to pre-approve Fractional Flow Reserve (FFR) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the trigger point injection provided on October 16, 2020.
You asked the Plan to waive the copayment for the trigger point injection. You say that you had a trigger point injection which is not what you think of as a surgery. 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 $220 copayment for each Medicare-covered surgery at an outpatient hospital facility. You have been asked to pay a $220 copayment for the trigger point injection. The trigger point injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the trigger point injection is considered a surgical procedure.
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 trigger point injection provided on October 16, 2020.
Your complaint that the injection was ineffective 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (DME) provided on
August 21, 2020.
You asked the Plan to pay for the DME. 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 DME. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for DME provided on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a second opinion with an OON provider. You say that the requested out-of-network provider is medically necessary for a second opinion The Plan denied your request. The Plan says the requested out-of-network provider is not medically necessary for a second opinion
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 provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a second opinion with an OON provider. Our reviewer says that the requested out-of-network provider is not medically necessary for a second opinion. Our physician reviewer found the enrollee is diagnosed with endometrial cancer that is described as aggressive. Based on the documentation provided, the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to the in-network tertiary level facility on May 4, 2021. There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested out-of-network provider. The surgery is standard surgery for a gynecologic oncologist. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's 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 a second opinion with an OON provider have not been met. 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 a second opinion with an OON provider. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that based on Medicare guidelines, IRF services do not meet the requirements for approval.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of stroke, heart disease, hypertension and is living at home with increasing complaints of weakness despite recent physical therapy services. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory test provided on November 2, 2020.
You asked the Plan to waive the copayment for the laboratory test. You say that you should not have an additional copayment for these tests. 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 $5 for Medicare-covered laboratory tests. You have been asked to pay a $5 copayment for the laboratory test. The laboratory test 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 laboratory test provided on November 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan.

You asked the Plan to waive the copayment for the CT scan. You say that this is the first time you had a copayment and you usually do not have a copayment for services related to your lung cancer. 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 $200 copayment for all other diagnostic and nuclear medicine radiological services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $200 copayment for the CT scan.

You have been asked to pay a $119.99 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on December 16, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, 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) on May 22, 2020, 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) provided on December 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 19, 2020.
You asked the Plan to pay for the ambulance services. You say that two ambulances arrived from one call by my daughter. The Plan denied your request. The Plan says these services are not a covered benefit.
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 July 19, 2020. 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 services provided on July 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on September 10, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the Centers for Medicare and Medicaid Services (CMS) website, shows the enrollee was enrolled in hospice from June 22, 2020 through September 10, 2020 and September 15, 2020 through September 20, 2020. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on September 10, 2020. Per the hospice regulations, the claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on 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 . The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on August 17, 2020.
You asked the Plan to pay for a shoulder-elbow-wrist-hand orthosis. You say that the requested item is a necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because there is no documentation of an established relationship between the enrollee and the ordering physician.
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 pay for a shoulder-elbow-wrist-hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the right shoulder. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a shoulder-elbow-wrist-hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth for teeth #4 and 29 (D3320), inhalation of nitrous oxide/analgesia (D9230), bone replacement graft for ridge preservation for tooth #2 (D7953).

You asked the Plan to pre-approve endodontic therapy, premolar tooth for teeth #4 and 29, inhalation of nitrous oxide/analgesia, bone replacement graft for ridge preservation for tooth #2. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 endodontic therapy, premolar tooth for teeth #4 and 29 (D3320), inhalation of nitrous oxide/analgesia (D9230), bone replacement graft for ridge preservation for tooth #2 (D7953).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the enrollee requires additional time in a SNF to ensures he is well enough to be self-sufficient. The Plan denied your request. The Plan says that the enrollee no longer requires skilled services and the continuation of SNF is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies (T4522).

You asked the Plan to pre-approve incontinence supplies. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under your contractual policy or by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4522).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for CT of the head or brain (70450) provided on November 21, 2020.
You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says that CPT code 70450 is a column II code to another service that has already been paid for the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 70450 is supported in the record. Specifically, the record indicates that the column I and column II codes were rendered by different providers. NCCI edits do not apply to separate providers. Based on this information, we decided that Medicare rules for coverage of the CT of the head or brain have been met. Therefore, we decided that the Plan has to pay for CT of the head or brain (70450) provided on November 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on August 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 (chest x-ray) and 77001 (fluoroscopic guidance). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 77001. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on August 5, 2020.