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

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) services (77049)
provided August 2, 2019.
You asked the Plan to pay for the MRI. You say that you expect to be reimbursed according to Medicare rates.
The Plan denied your request. The Plan says this service is not covered by Medicare on this type of bill.
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 77049 is not supported for separate payment. Specifically, the record shows that this
code was billed on type of bill 13x. This code is not payable by Medicare when submitted on type of bill 13x as
this code is not recognized by the Outpatient Prospective Payment System (OPPS). This service may be paid
when submitted on a different bill type or with an alternate code recognized by OPPS. Based on this
information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided
that the Plan does not have to pay for magnetic resonance imaging (MRI) services (77049) provided August 2,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on September 24, 2019.
You asked the Plan to pay for the comprehensive oral evaluation and intraoral x-rays. You say that you contacted the Plan and they provided you with this dentist saying this was the only provider available. You also say that there were no in-network providers in the area you live. The Plan denied your request. The Plan says this dentist is an out-of-network provider. The Plan also says that there is no call on file in which this provider was discussed, and you were referred elsewhere.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 5, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you thought you wouldn't have charges if this was a part of the yearly checkup. You say that you were not informed you would be charged. 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 a $10 copayment for bloodwork drawn at a physician's office and sent to an independent lab for processing. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on August 23, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you were informed everything would be paid in full. 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 a $225 copayment for each in-network Medicare covered advanced imaging service. You have been asked to pay $224, which is less than the standard $225 copayment for the MRI. The MRI 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 MRI provided on August 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam (PBT) and image guided radiation therapy (IGRT).
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says IGRT is used if proton beam therapy is called for. PBT is not medically necessary for the enrollee.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy. Any potential benefit or detriment of proton therapy over standard IMRT is investigational. Other treatment approaches are highly effective and well tolerated. Thus, whether proton therapy affords a benefit over other standard approaches for prostate cancer is an area of investigation and remains controversial. There are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam (PBT) and image guided radiation therapy (IGRT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis services provided on July 26, 2019.
You asked the Plan to pay for the arthrocentesis services. 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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. We find that CPT code 20611 is not supported in the medical record. Specifically, the submitted medical records do not indicate that arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting, was performed. The plan notes that there is a more appropriate CPT code that should be used to bill the documented service. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis services have not been met. Therefore, we decided that the Plan does not have to pay for the arthrocentesis services provided on July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 10, 2019 to October 29, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries
(A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery
Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to
corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips,
lancets, control solution, and batteries provided from August 10, 2019 to October 29, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that you have tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 17, 2019 to November 5, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 17, 2019 to November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 29, 2019 to October 17, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 29, 2019 to October 17, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electroconvulsive therapy provided in an inpatient setting.
You asked the Plan to pre-approve the electroconvulsive therapy provided in an inpatient setting. You say that the medical records provided support the need for inpatient electroconvulsive therapy. The Plan denied your request. The Plan says the enrollee could be treated at a lower level of care and could receive electroconvulsive therapy in an outpatient setting.
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 electroconvulsive therapy provided in an inpatient setting. Our reviewer says that it is not medically reasonable and necessary for the enrollee to receive electroconvulsive therapy in an inpatient setting. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on January 15, 2020 with Major Depressive Disorder, Recurrent, Severe without Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment. The enrollee does not have dangerousness to self or others and was compliant with her treatment. The enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. 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 electroconvulsive therapy provided in an inpatient setting have not been met. Therefore, we decided that the Plan does not have to pre-approve electroconvulsive therapy provided in an inpatient setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided on May 3, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided on May 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on January 9, 2019.
You asked the Plan to pay for the advance care planning services. 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 payable.
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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. We find that CPT code 99497 is not supported in the medical record. Specifically, the benefit for this service is included in the payment/allowance for another services/procedure that has already been processed and paid. The plan notes that the services would be payable with the appropriate modifier for this diagnosis code, however, a corrected claim was not submitted. Based on this information, we decided that Medicare rules for coverage of the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on January 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on July 24, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered to on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on
July 2, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 95972 is not supported.
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 95972 is electronic analysis of implanted brain, spinal
cord or peripheral stimulation device with complex spinal cord or peripheral nerve stimulator programming.
We find that CPT code 95972 is not supported in the medical record. Specifically, there is no documentation of
electronic analysis of an implanted neurostimulator pulse generator/transmitter. 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 services rendered to the enrollee on July 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 2, 2019 to October 21, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 2, 2019 to October 21, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 23,
2020.
You asked the Plan to pre-approve SNF care. You say that you need continued services due to your worsening
condition. The Plan denied your request. The Plan says that SNF care is no longer medically necessary.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. The delivery of this notice is not valid until the enrollee (or the enrollee's representative)
has signed and dated the notice to indicate that he or she has received the notice and can comprehend its
contents.
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before January 23, 2020. The submitted documentation does not include a NOMNC that was signed
and dated by the enrollee or the enrollee's representative. The Plan must pay for SNF services until the 100-day
SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore,
we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 23,
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.