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

We decided that the Plan does not have to pay for a Diagnostic Digital Breast Tomosynthesis (77061) provided February 25, 2020.
You asked the Plan to pay for the Diagnostic Digital Breast Tomosynthesis. You say that the service was medically necessary. The Plan denied your request. The Plan says this code 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 77061 is not supported in the medical record. Specifically, code 77061 is not valid for Medicare purposes per the 2020 Year National Physician Fee Schedule. Based on this information, we decided that Medicare rules for coverage of the Diagnostic Digital Breast Tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for a Diagnostic Digital Breast Tomosynthesis (77061) provided February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone scan (77080) provided December 24, 2019.
You asked the Plan to pay for the bone scan. You say that the bone scan was medically necessary. The Plan
denied your request. The Plan says the record shows you already had a bone scan within 24 months of the
service date and medical records were not provided to support the need for more frequent scans.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due.
We looked at the file and Medicare rules. The enrollee had exhausted their benefit for a screening bone scan
before the date of service. A test was already conducted on November 23, 2018. No medical records were
provided to support that a test was needed before the enrollee was eligible for another screening test. Based on
this information, we decided that Medicare rules for coverage of the bone scan have not been met. Therefore,
we decided that the Plan does not have to pay for a bone scan (77080) provided December 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of an impacted tooth (CPT D7230).
You asked the Plan to pre-approve the removal of an impacted tooth. You say that this surgical extraction is
emergent and needed to relieve pain. The Plan denied your request. The Plan says the service being requested
is not covered under the enrollee's benefit package.
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 the
removal of an impacted tooth (CPT D7230).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray of the spine (72100) provided on March 10, 2020
by an out of network (OON) provider.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary and should be
covered. The Plan denied your request. The Plan says there were network providers available. The service was
not emergent or preauthorized.
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 service 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 x-ray of the spine (72100) provided on March 10, 2020 by an out of network
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a crown (D2750) provided January 23, 2020.
You asked the Plan to waive the coinsurance for the crown. You say that the second crown was never placed so you should be refunded the coinsurance. The Plan denied your request. The Plan says the record shows 2 crowns were placed and the correct cost sharing was applied.
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 70% coinsurance for crowns provided in-network. You have been asked to pay a 70% coinsurance for the crown. 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 a crown (D2750) provided January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a home blood pressure monitor.
You asked the Plan to provide a home blood pressure monitor. You say that your doctor recommended a home blood pressure monitor to aid in your heart health. The Plan denied your request. The Plan says home blood pressure monitors are only covered for dialysis patients.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to provide a home blood pressure monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on November 18, 2019.
You asked the Plan to pay for the non-emergent ambulance services. You say that the transport was medically
necessary. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the non-emergent ambulance services have not been met. Therefore, we decided that the Plan does
not have to pay for ambulance services provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 30,
2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
all non-emergent services received with a non-Plan provider require approval by the Plan prior to the services
being rendered.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for subsequent nursing facility care provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D3348) provided February 17, 2020.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this dentist has opted out of the Medicare program and is not eligible for
reimbursement.
The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given
by a physician or other practitioner who has opted out of Medicare.
We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare.
Based on this information, we decided that Medicare rules for coverage of the dental services have not been
met. Therefore, we decided that the Plan does not have to pay for dental services (D3348) provided February
17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services and laboratory services provided on
February 21, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the
providers are not in-network and there is no authorization on file.
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 providers in this case are not a network providers with the Plan. 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 physician's services and laboratory services provided on
February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for special procedure to add tooth to existing partial denture,
tooth 25 (D5650) provided February 6, 2020.
You asked the Plan to pay for the dental services. You say that you were told by a plan representative that you
could go to any doctor that you choose to go to and she said not to worry that you were covered. You followed
all directions and this be covered. The Plan denied your request. The Plan says this service is not covered under
the plan benefits.
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 special
procedure to add tooth to existing partial denture, tooth 25 (D5650) provided February 6, 2020.
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 you need wound care and do not think a skilled nursing facility is adequate. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In this case, you are mostly minimal/standby assistance for functional transfers and activities of daily living. A longer, less intensive duration of therapy will allow for measurable gains to be attained within a reasonable, predicted period. An IRF level of care is not warranted. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for the approved surgery.
You asked the Plan to pre-approve inpatient admission. You say that the requested inpatient admission for the
approved surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient
admission for the approved surgery 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 inpatient admission. Our reviewer says
that the requested inpatient admission for the approved surgery is not medically necessary. Our physician
reviewer found the enrollee is with stage 4 sacral ulcer secondary to T-6 paralysis from a gunshot wound
undergoing 2 stage procedure for sacral wound debridement and closure. This is not an inpatient required
procedure. There is unclear clinical justification as to why observation level of care is not sufficient for this
enrollee. Medical necessity for inpatient level of care is not determined.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve inpatient admission for the approved surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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.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 records do not indicate that there are significant, or complex medical/nursing issues that could not beaddressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveout of network physician visit.You asked the Plan to pre-approveout of network providers. You say that you prefer to see the requested provider.The Plan denied your request. The Plan says this provider is not in network.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 is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approveout of network physician visit.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy.You asked the Plan to pre-approve the HBO therapy. You say that the enrollee has recurrent diabetic foot ulcers. The appellant says that past diabetic ulcers have healed by HBO therapy. The appellant says that the current ulcers are not improving with standard wound care treatment and that she is a candidate for HBO therapy in order to prevent amputation. The appellant says that noncompliance with her medications is not a reason to deny her HBO therapy.The Plan denied your request. The Plan says that the information received did not establish the medical necessity of the proposed treatment.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 the HBO therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has non-healing ulcers. The enrollee has responded to HBO therapy in the past. Information was provided on the size of the lesions. The level of the HbA1c is not a criterion for qualifying for therapy. Our physician reviewer did not find that vascular studies would change immediate wound management. Ideally, wounds would heal without an invasive procedure. Poor compliance is not a reason to deny therapy.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 HBO therapy have been met.Therefore, we decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine transport for a total of 206 miles.You asked the Plan to pre-approve these services. You say that you have no other means of transportation.The Plan denied your request. The Plan says the request exceeds the benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 24 one-way trips within a 50 mile limit. We looked at your request, the records in the case file, and the rules. The file shows that you are requesting transportation for a total of 206 miles (103 miles per one-way trip). Based on this information,we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a routine transport for a total of 206 miles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that this enrollee requires this device to help control blood sugar. The Plan denied your request. The Plan says the LCD criteria for the CGM have not been met as this enrollee does not appear to use insulin.
The Plan must follow Medicare rules. Medicare rules say that CGMs are covered for enrollees with diabetes who require three or more daily insulin injections with frequent adjustment by the enrollee based on the glucose testing results. In this case, the progress notes do not clearly show that insulin is required by this enrollee. A form submitted by the provider indicates that insulin is used but that it is used once weekly. This may be a reference to the weekly Trulicity injection, but this still does not meet the criterion which requires three or more daily injections. As such, we find that the Medicare coverage criteria for the requested CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652, E0667) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an OON pneumatic compression device. You say that you doctor says the requested OON supplier provides a device that works better than others on the market. The Plan denied your request. The Plan says the requested items are available in-network.
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 the pneumatic compression device (E0652, E0667) to be provided by an out of network (OON) provider.