Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided on January 31, 2021.
You asked the Plan to pay for therapeutic CGM. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the records do not support that the enrollee met the Medicare criteria for this therapeutic continuous glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided on January 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673) provided to the enrollee on October 13, 2020.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says this is an administrative determination for lack of medical documentation and is not based on clinical criteria for medical necessity. 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 DME have not been met. With the information we have, we cannot determine if a physician's order was given, how the enrollee came to you, the referring provider, and/or whether the services are necessary. All providers are required to furnish necessary information to the health plan when requested. The provider's staff is responsible for submitting information to the health plan for review and determination. Therefore, we decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673) provided to the enrollee on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment services provided on July 13, 2020.
You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration because the testing was medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease.
The Plan follows Medicare rules. The rules explicitly say that cardiovascular risk assessment testing must be billed with the CPT codes as referenced in the Medicare rules section. We looked at your request, the file and Medicare rules. Based on this information we decided that Medicare coverage criteria have not been met. Specifically, this testing has not been billed with the appropriate CPT codes for cardiovascular risk assessment testing. Additionally, the documentation submitted does not include any clinical information to determine why this testing was ordered or how it will affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment services provided on July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on January 29, 2021 to February 4, 2021.

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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on January 29, 2021 to February 4, 2021.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81407, 81408, 81439) provided on September 28, 2020.
You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this is supported in
the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients
with suspected or documented CV disease because panel testing is not specific to a given patient's lipid
abnormality or disease.
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive
cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a
comprehensive cardiovascular genetic panel (81407, 81408, 81439) provided on September 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on June 15, 2020.

You asked the Plan to waive the copayment for an x-ray. You say that you already paid you $15 copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $15 copayment for outpatient diagnostic tests/x-ray. 

You have been asked to pay a $15 copayment for an x-ray. When additional services are provided during an office visit, the correct additional copayment is applied; therefore, the correct copayment has been applied. An x-ray falls within the outpatient diagnostic tests/x-ray 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 an x-ray provided by a participating provider on June 15, 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. The Plan denied your request. The Plan says IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a right ankle fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73600) provided on January 29, 2021.
You asked the Plan to pay for an x-ray. You say that you are permitted to bill both the professional and technical component of this code. The Plan denied your request. The Plan says this is not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component (representing the physician's interpretation of the test results) is a separately billable physician service under Part B. We looked at the file and Medicare rules. The records show that the enrollee was a SNF resident at the time this service was provided, but this service was not billed with a modifier to indicate only the profession component of the service is being billed.
Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (73600) provided on January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary to be safe enough to
go home. The Plan denied your request. The Plan says movement to a skilled nursing facility is not medically
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided,
you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in
the acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until you are stable to
transfer to 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee from January 1, 2021, to January 21, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says this claim was not billed appropriately. The Plan states the provider did not bill with the required rate code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to an omission of the appropriate codes. Medicare billing criteria are not met. 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 outpatient mental health services provided to the enrollee from January 1, 2021, to January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a prostate gene panel (81162, 81206, 81292, 81295, 81298, 81301, 81317, 81321, 81401) provided on August 13, 2020.
You asked the Plan to pay for a prostate gene panel. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that as Comprehensive
Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX, and it is a test not currently satisfactorily described by any existing CPT code. Therefore, to report a CGP service, test providers should use CPT code 81479 at this time. We find that CPT codes 81162, 81206, 81292, 81295, 81298, 81301, 81317, 81321, and 81401 are not supported in the medical record. Specifically, these codes were used to report a CGP service, which should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of a prostate gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a prostate gene panel (81162, 81206, 81292, 81295, 81298, 81301, 81317, 81321, 81401) provided on August 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for rotary wing air ambulance (A0431) and rotary wing air mileage (A0436) provided October 31, 2020.
You asked the Plan to pay for the air ambulance services. You say that your servers have been down within your billing office. During this time, you have been without access to patient and billing information needed to successfully submit your appeals within the time constraints given by your office. The Plan denied your request. The Plan says the information provided does not support medical necessity for ambulance transport. Cardiology services were available at the hospital where the enrollee sought emergency room service.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation did support that the enrollee suffered from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation did not support that the enrollee's condition was such that the time needed to transport by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. 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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for rotary wing air ambulance (A0431) and rotary wing air mileage (A0436) provided October 31, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided to the enrollee o February 18, 2021.
You asked the Plan to pay for genetic testing. You say that this claim should be paid. The Plan denied your request. The Plan says that based on the Medicare regulations, this case was administratively denied because an incorrect code was used. The Plan states their decision is based on guidance found in Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in [Solid Tumor] Cancers (A55624), Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer (A55197) and Medicare Local Coverage Article (A57936): Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plans are expected to use Medicare regulations that have a MAC B jurisdiction designation for either the state the enrollee lives in or the state in which the provider is located. The regulations referenced by the Plan do not show MAC B jurisdiction for the state the enrollee lives in or in the state provider is in and therefore do not apply. This means, the Plan has not substantiated its denial as the appropriate Medicare regulations were not used to determined coverage or coding guidelines. Therefore, we decided that the Plan has to pay for genetic testing provided to the enrollee o February 18, 2021.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 1, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original
Medicare is responsible for payment.
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 the laboratory services provided on September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on November 9, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and paid due to medical necessity The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring 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 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 genetic testing provided on November 9, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by
Medicare.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device
is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram (77063) provided July 13, 2020.

You asked the Plan to pay for the mammogram. You say that the services were medically necessary. The Plan
denied your request. The Plan says billing requirements are not met.

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 77063 is not supported in the medical record. Specifically, an add-on code was billed
without the primary procedure being approved. Based on this information, we decided that Medicare rules for
coverage of the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for a
mammogram (77063) provided July 13, 2020.