Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve dermatology services. You say that you would like to continue to see the provider you have been seeing. The Plan denied your request. The Plan says there are in-network providers available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider.

Please ask the Plan for a list of in-network providers available for these services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a replacement continuous glucose monitor.

You asked the Plan to provide a replacement continuous glucose monitor (A9276, S9277). You say that the
enrollee needs this system to use real time glucose readings with the pump. The Plan denied your request. The
Plan says the enrollee's current CGM is still under reasonable useful lifetime and the requested CGM is not
covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that this code is not used to bill for supplies used with
a covered therapeutic continuous glucose monitor.

We looked at the file and Medicare rules. This CGM is still within the 5-year RUL and the documentation
submitted does not show that the enrollee's CGM is irreparably worn, irreparably damaged, or that the enrollee
has had a change in medical condition to warrant a new CGM. The requested CGM is interstitial and not
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a replacement
therapeutic continuous glucose monitor (A9276, S9277) have not been met. Therefore, we decided that the
Plan does not have to provide a replacement continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for clavicle x-rays (73000) and the transportation of portable x-ray equipment (R0070) provided on November 16, 2020.

You asked the Plan to pay for clavicle x-rays and the transportation of portable x-ray equipment. You say that these codes are supported. The Plan denied your request. The Plan says these services are not documented.

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 73000 is radiologic examination; clavicle, complete. The definition of R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. 

We find that CPT codes 73000 and R0070 are not supported in the medical record. Specifically, the submitted medical records do not include documentation of x-rays of the clavicle. The records also do not include documentation confirming that x-ray equipment was transported on this date and only one patient was seen. Based on this information, we decided that Medicare rules for coverage of clavicle x-rays and the transportation of portable x-ray equipment have not been met. Therefore, we decided that the Plan does not have to pay for clavicle x-rays (73000) and the transportation of portable x-ray equipment (R0070) provided on November 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97163) provided November 7, 2019.

You asked the Plan to pay for the physical therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 97163 is not supported in the medical record. Specifically, insufficient records were provided to support the billed services. The plan made multiple requests for additional documentation and none was received. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97163) provided November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 2.

You asked the Plan to pre-approve the dental service. You say that your tooth has a cracked crown. You also say that it gives off a foul odor. The Plan denied your request. The Plan says core build up 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 pre-approve core build up (D2950) for tooth # 2.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the arthrocentesis provided on November 17, 2020.

You asked the Plan to waive the co-payment for the arthrocentesis. You say that you the hospital provided no service and that should not be charged this much. You say that the injection is not 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co-payment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $295 co-payment for the arthrocentesis. The arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the arthrocentesis 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 co-payment for the arthrocentesis provided on November 17, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for laparoscopic cholecystectomy (47562) provided on June 26, 2020.

You asked the Plan to pay for laparoscopic cholecystectomy. You say that the service was medically necessary. The Plan denied your request. The Plan says that the provider was out of network.

The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health.

The rules also say that when a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.

We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. And, even though, the provider who performed the surgery was out-of-network, the facility you received care from was in-network. This means the facility is a contract plan provider and can refer out-of-network providers to perform covered services. Therefore, we decided that the Plan has to pay for laparoscopic cholecystectomy (47562) provided on June 26, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 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 the testing is not covered.

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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup procedures (D2950) for tooth #19 and #30.

You asked the Plan to pre-approve core buildup procedures. You say that this service is necessary for these teeth. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup procedures (D2950) for tooth #19 and #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 3, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Boost Plus (B4152).

You asked the Plan to pre-approve this item. You say that this nutritional supplement is medically necessary for the enrollee. The Plan denied your request. The Plan says Enteral nutrition products that are administered orally are not covered under the enrollee's contractual policy or by original Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 

The item you asked the Plan to pre-approve is considered a nutritional supplement. Although this may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage for this item. Therefore, we decided that the Plan does not have to pre-approve Boost Plus (B4152).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for unlisted molecular pathology procedure, Apolipoprotein AI, APOA1
full gene analysis (CPT code 81479) provided on May 18, 2020.

You asked the Plan to pay for the services. You say that the procedure was a very critical diagnosis of your
amyloidosis.] The Plan denied your request. The Plan says that this service is not covered.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.

You were referred for the services by a contract provider. The file does not show that the Plan provided notice
that the services would not be covered. Under Medicare rules, this means the services is considered approved
by the Plan. Therefore, we decided that the Plan has to pay for unlisted molecular pathology procedure,
Apolipoprotein AI, APOA1 full gene analysis (CPT code 81479) provided on May 18, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator (CPT code E0466), for the enrollee.

You asked the Plan to pre-approve the ventilator. You say that the ventilator is necessary. The Plan denied your
request. The Plan says the Medicare rules have not been met.

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 ventilator have not been met. The enrollee's doctor prescribed a
ventilator to help the enrollee's breathing at various times of the day (night and day) because of the enrollee's
lung disease.

Medicare does not cover ventilators used in this way. Medicare will cover a device called respiratory assist
device that has advanced features, and the plan will cover this when medically necessary. Therefore, we
decided that the Plan does not have to pre-approve home ventilator (CPT code E0466), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve the special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says you must have one or more chronic conditions (from a list of specific conditions identified by your health Plan) that are medically complex, life-threatening, or significantly limiting your health or its performance in general. You do not require intensive care coordination and you do not have a high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination.

We looked at the file and the Plan's rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for application of a modality to 1 or more areas; traction,
mechanical (CPT code 97012), therapeutic procedure (CPT Code 97110), and office evaluation (CPT Code
99203) provided from June 25, 2020, through November 25, 2020, by an out-of-network provider.

You asked the Plan to pay for the chiropractic services. You say that the services were processed incorrectly,
and you feel the denied services should be covered. The Plan denied your request. The Plan says these services
are not covered by Medicare or your Plan.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for application of a modality to 1 or more areas; traction, mechanical (CPT code
97012), therapeutic procedure (CPT Code 97110), and office evaluation (CPT Code 99203) provided from
June 25, 2020, through November 25, 2020, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Keytruda provided December 28, 2020, to February 8, 2021.
You asked the Plan to pay for Keytruda. You say that this drug was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Keytruda injections were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 pay for Keytruda. Our reviewer says that the requested drug injections were not medically necessary and reasonable. Our physician reviewer found the patient has been diagnosed with non-small-cell lung carcinoma. Keytruda is not FDA-approved for the enrollee's diagnosis. Furthermore, it is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Approval requires epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) wildtype. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pay for Keytruda provided December 28, 2020, to February 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on March 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional OT.

You asked the Plan to pre-approve the OT. You say that you cannot move, or flip documents and it is difficult for you to do things and the nursing home does not assist you. The Plan denied your request. The Plan says additional OT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 additional OT. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found occupational therapy (OT) is generally accepted as specific and effective therapy for muscle weakness. The available documentation is insufficient to demonstrate that continued OT is required to safely and effectively provide treatment for you. The documentation does not support that you are participating in a maintenance program.

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 additional OT have not been met. Therefore, we decided that the Plan does not have to pre-approve additional OT.