Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam filling (D2150) provided on October 15, 2020.

You asked the Plan to pay for the dental service. You say that this should be covered. The Plan denied your request. The Plan says amalgam filling is not listed as 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the amalgam filling (D2150) provided on October 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or in the home with home health care services.
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 your condition does not meet Medicare criteria for continued 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot (L4387) provided October 2, 2020.
You asked the Plan to waive the coinsurance for the walking boot. You say that you do not believe you should be charged a coinsurance for the item as it was uncomfortable. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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% coinsurance for durable medical equipment. You have been asked to pay a total cost share of $27.15 for the walking boot ($135.74 Medicare allowed amount x 20% coinsurance). This item falls within the durable medical equipment 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 coinsurance for the walking boot (L4387) provided October 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 25, 2020.

You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place then triaged to BLS. 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 May 25, 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 May 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The Plan denied your request. The Plan says the requested Aranesp is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Aranesp. Our reviewer says that the requested Aranesp is not medically necessary. Our physician reviewer found the enrollee's physician is concerned about the enrollee's hemoglobin. The enrollee also has stage 5 chronic kidney disease. The use of Aranesp is not FDA-approved for the enrollee's diagnosis without other causes of anemia being ruled out and corrected. This enrollee has iron deficiency anemia that has not been corrected and no B12 and folate have been checked. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract removal provided on November 10, 2020.

You asked the Plan to waive the copayment for cataract removal. You say that the enrollee cannot afford the charges and you were not aware of them. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

The enrollee has been asked to pay a $350 copayment for cataract removal. Cataract removal falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract removal provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says research has not found this treatment to be helpful for treatment of the pain.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found cooled and pulsed radiofrequency ablation do not meet the criteria of the LCD. Therefore, the request is considered not medically reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency ablation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on August 19, 2020.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that Cardiovascular Disease Screening shall be submitted with CPT code 80061, 82465, 83718 or 84478.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment have not been met. Specifically, this claim has not been billed with the appropriate CPT codes for cardiovascular disease screening. Additionally, the submitted documentation does not include any clinical information to verify if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 19, 2021 by an out of network (OON) provider.

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 Plan had network providers available who could have provided 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 physician services provided on January 19, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epoetin alfa-epbx for the enrollee.

You asked the Plan to pre-approve epoetin alfa-epbx. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that the member's current hemoglobin is more than 10 g/dl and this is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 epoetin alfa-epbx. Our reviewer says that epoetin alfa-epbx is not medically reasonable and necessary for the enrollee. Guidelines require that prior to initiating epoetin alfa-epbx a patient's hemoglobin be less than 10 g/dL. This patient's hemoglobin is greater than 10. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for epoetin alfa-epbx.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epoetin alfa-epbx have not been met.Therefore, we decided that the Plan does not have to pre-approve epoetin alfa-epbx for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on September 30, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the OON lab testing. You say that this was processed under an incorrect tax ID and should be paid. The Plan denied your request. The Plan says these services were provided OON and ordered by an OON physician. No authorization was obtained for these services, which were not emergent.

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 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 testing provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Rifton Activity chair (E1399).
You asked the Plan to pre-approve the Rifton Activity chair. You say that the enrollee needs the chair for support and provide positioning and comfort when sitting for feeding safety. When using the Rifton chair was able to be tilted to an angle that facilitated food and fluids ingestion. The Plan denied your request. The Plan says the requested item is primarily intended for comfort and convenience and is not primarily medical in nature.
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 the Rifton Activity chair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prostate cancer screening, prostate specific antigen (PSA) test (G0103) provided November 17, 2020.

You asked the Plan to pay for the Prostate cancer screening. You say that this annual test has never been denied. The denial indicates that the benefit has been exhausted and you do not understand this because you have been doing the same thing annually for many years. The Plan denied your request. The Plan says the maximum benefit has been exhausted.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The PSA test is covered once every 12 months. Based on review of the file a PSA test was provided on February 18, 2020 which is less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the Prostate cancer screening, prostate specific antigen (PSA) test (G0103) provided November 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee's needs are non-skilled.

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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled
therapy needs and is unable to participate in skilled therapy. The enrollee's care needs at this point are custodial
and can be provided at a lower level of care.

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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 30, 2020.
You asked the Plan to pay for the drug testing. 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.
In this case, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21
drug class(es), including metabolite(s) if performed.
We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service
on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug
testing coded G0482 provided on July 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast augmentation with implant.

You asked the Plan to pre-approve a breast augmentation with implant. You say that the requested breast augmentation with implant is medically necessary.The Plan denied your request. The Plan says the requested breast augmentation with implant is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a breast augmentation with implant. Our reviewer says that the requested breast augmentation with implant is not medically necessary. Our physician reviewer found the enrollee is with gender identity disorder who seeks to have breast augmentation. In this case, the record indicates that the enrollee has a preference to be female. The enrollee has active psychiatric conditions, including schizoaffective disorder.  There is no documentation of gender dysphoria and the enrollee is not on hormonal therapy. The requested treatment is 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 a breast augmentation with implant have not been met.Therefore, we decided that the Plan does not have to pre-approve a breast augmentation with implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses.
You asked the Plan to pre-approve eyeglasses. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you received eyeglasses on September 14, 2020, which is less than 2 years ago.
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 eyeglasses every 2 calendar years. We looked at the file and the Plan's rules. The Plan contract states that you are covered for eyeglasses every 2 calendar years. The file shows that you last received eyeglasses on September 14, 2020, which is less than 2 years ago. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on October 12, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 the services provided to the enrollee by an out-of-network provider on October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 28, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the requested item was medically necessary. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by the ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested item was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications 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 back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 28, 2020.