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

We decided that the Plan does not have to pay for established patient office or other outpatient visit, 10-19 minutes (CPT code 99212) and biopsy of lining of uterus (CPT Code 58100) provided to the enrollee on January 13, 2021, by an out-of-network provider.

You asked the Plan to pay for the services. You say that an authorization should not be needed as this is a specialist and are requesting review for reprocessing for payment of this claim. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 established patient office or other outpatient visit, 10-19 minutes (CPT code 99212) and biopsy of lining of uterus (CPT Code 58100) provided to the enrollee on January 13, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of skin and tissue, 20.0 sq cm or less (CPT code 11042) provided to the enrollee on January 12, 2021, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 removal of skin and tissue, 20.0 sq cm or less (CPT code 11042) provided to the enrollee on January 12, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services described by current procedural terminology (CPT) code 99291 provided on June 15, 2020.
You asked the Plan to pay for CPT code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the documentation does not support the billing of CPT code 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, CPT code 99291 is a time-
based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for June 15, 2020 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of CPT code 99291. Based on this information, we decided that Medicare rules for coverage of CPT code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services described by current procedural terminology (CPT) code 99291 provided on June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the outpatient initial observation care provided to the enrollee on January 23, 2020.

You asked the Plan to pay for these services. You say that this should be reprocessed and paid. The Plan denied your request. The Plan says that that the services were not referred by a network provider or rendered in a participating facility.

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. 

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. Therefore, we decided that the Plan has to pay for the outpatient initial observation care provided to the enrollee on 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Empliciti for solution 400 mg.
You asked the Plan to pre-approve Empliciti. You say that this drug is medically necessary. The Plan denied
your request. The Plan says the requirements for coverage have not been met.
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 pre-approve Empliciti. Our reviewer says that this
drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the
enrollee has been diagnoses with light chain multiple myeloma. In this case, the use of Empliciti is not FDAapproved
for the enrollee's condition. In addition, the Medicare-approved compendia do not support the use of
this drug at this time for the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Empliciti have not been met. Therefore, we decided that the Plan does not have to pre-approve Empliciti for solution 400 mg.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is an 87-year-old female who patient appears to be tolerating tube feeds and is weaning gradually from vent support; however, additional short term acute care services are required and can safely be received at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. In addition, there are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time until the patient's acute care treatment has completed.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab. The Plan denied your request. The Plan says there is no need for physician supervision 3 times per week.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for dizziness and weakness. Her medical conditions are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria have 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 Hyalgan. Our reviewer says that step therapy criteria have not been met. Our physician reviewer found that the enrollee is a 77 year old female with osteoarthritis of the knee. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) likely be less effective and/or likely have adverse effects for 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the urgent care visit to obtain a COVID-19 test
provided on December 22, 2020.

You asked the Plan to waive the copayment for the urgent care visit. You say that you would like the Plan to
reconsider your request. The Plan denied your request. The Plan says that the correct copayment has applied.

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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Per Medicare, Medicare Advantage Plans can't charge copayments, deductibles,
or coinsurance for clinical lab tests to detect or diagnose COVID-19. In this case, the medical records clearly
show the enrollee was at this provider strictly for a COVID-19 test. No other services were performed during
this visit. Therefore, we decided that the Plan has to waive the copayment for the urgent care visit to obtain a
COVID-19 test provided on December 22, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adjunctive pre-diagnostic testing services (D0431), gingival irrigation services (D4921), and core buildup services (D2950).

You asked the Plan to pre-approve adjunctive pre-diagnostic testing, gingival irrigation, and core buildup. You say that you are in a lot of pain and are unable to sleep due to the condition you are in. The Plan denied your request. The Plan says the services which remain in dispute are not covered benefits under your contract.

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 services which remain in dispute are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve adjunctive pre-diagnostic testing services (D0431), gingival irrigation services (D4921), and core buildup services (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.
You asked the Plan to provide a therapeutic continuous glucose monitor system. You say that the enrollee needs a therapeutic continuous glucose monitor system because the enrollee's blood sugar has been fluctuating for a few months. The Plan denied your request. The Plan says they did not get documentation that the enrollee is testing at least 4 times a day or there are frequent adjustments to the insulin treatment.
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. We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a
therapeutic continuous glucose monitor system have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies provided to the enrollee on October 14, 2020.

You asked the Plan to pay for the CGM supplies. You say that these services were medically necessary. The Plan denied your request. The Plan says that that this is not covered.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced 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 pay for the CGM supplies. Our reviewer says that the CGM supplies were medically reasonable and necessary for the enrollee. The patient has diabetes mellitus, is on multiple daily injections and is instructed to check blood glucose to avoid lows and helps adjust her insulin doses at meals. Our physician reviewer found that the enrollee's condition meets Medicare criteria for the CGM supplies.

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 CGM supplies have been met. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies provided to the enrollee on October 14, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (CPT 01200) provided to the enrollee on October 13, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a review of the documentation shows that a specific laterality is 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 01200 is "Anesthesia for closed procedure on hip joint." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the provider billed 01200 with a primary diagnosis of M16.9 - Osteoarthritis of hip, unspecified, but the medical records specify services were performed on the right hip, therefore a more appropriate diagnosis is available to submit to the health plan. Medicare rules state Providers must bill correctly and with the most specific codes available, therefore this service is not eligible for reimbursement consideration.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (CPT 01200) 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 hereditary cardiovascular panel provided on December 8, 2020.
You asked the Plan to pay for the hereditary cardiovascular panel. You say that you would like reconsideration because this testing is 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 disease.
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 pay for the hereditary cardiovascular panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited medical history provided other than listed diagnoses. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. Cardiac gene variant testing is not currently recommended for general risk stratification and screening. 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 hereditary cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular panel provided on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic profiling on oncology biopsy of ovarian lesions, assays of two proteins (CPT code 81500) provided to the enrollee on November 20, 2020.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says these services are not authorized because molecular genetic hereditary predictive screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.

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, the laboratory testing, 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 genetic profiling on oncology biopsy of ovarian lesions, assays of two proteins (CPT code 81500) provided to the enrollee on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom jaw appliance (21499) provided on February 12,
2021.

You asked the Plan to pay for the dental item. You say that your insurance will not cover this device. You say
that this was for a custom jaw appliance to relieve tremendous pain from temporomandibular joint (TMJ) and
subsequent jaw lock. You also say that without this appliance, you would need surgery to correct this. The Plan
denied your request. The Plan says the custom jaw appliance is not covered by the plan or by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the custom jaw appliance (21499) provided on February 12, 2021.