Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a limited evaluation (D0140), intraoral x-rays (D0220, D0230), bitewing x-rays (D0274) and extractions (D7140) provided on October 22, 2020 and November 3, 2020 by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you requested a list of covered dentists and were told that dental coverage was provided separately from medical coverage and out-of-network services could be covered under the PPO (Preferred Provider Organization) plan. The Plan denied your request. The Plan says out-of-network services are not covered under the mandatory supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental care is not among those covered under this benefit. The Plan has indicated that you are enrolled only in the mandatory dental benefit, which does not offer out-of-network coverage. The contract shows that there is an additional optional supplemental dental benefit that offers some out-of-network coverage for an additional monthly premium, however you are not enrolled in this benefit. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a limited evaluation (D0140), intraoral x-rays (D0220, D0230), bitewing x-rays (D0274) and extractions (D7140) provided on October 22, 2020 and November 3, 2020 by an out-of-network provider.

Your complaint about a potential miscommunication from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pelvic ultrasound (CPT code 76856) and abdominal ultrasound (CPT Code 76705) provided on December 8, 2020.

You asked the Plan to waive the copayment for the ultrasounds. You say that you received an annual checkup of your kidneys and had microscopic amount of blood in your urine. You state that in the past you only paid for the laboratory fees. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Review of the file show that you received a pelvic ultrasound (CPT code 76856) and abdominal ultrasound (CPT Code 76705) provided on December 8, 2020. You were asked to pay a $110 copayment for the pelvic ultrasound. The Medicare-allowed amount for the abdominal ultrasound is less than the set $110 copayment; therefore, you have been asked to pay the lesser amount of $95.51 for the abdominal ultrasound. Your total cost share responsibility is $205.51 ($110 + $95.51 = $205.51). Your 2020 EOC states that enrollees must pay a $110 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 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 pelvic ultrasound (CPT code 76856) and abdominal ultrasound (CPT Code 76705) provided on December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. The documentation does not support that an additional twenty-five (25) days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the autologous serum tears provided September 23, 2020.

You asked the Plan to pay for the autologous serum tears. You say that you would like the claim to reprocess
this claim and approve for payment. The Plan denied your request. The Plan says the service provided were 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 pay for the autologous serum tears. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found you have a diagnosis of bilateral dry eye and keratoconus. The provided medical
records are insufficient to establish the medical necessity and reasonableness of the requested service as
defined by Medicare rules. The elements of the coverage criteria are not satisfied.

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 autologous serum tears have not been met. Therefore, we decided that the
Plan does not have to pay for the autologous serum tears provided September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
enrollee is able to control the power options using their own switches.

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 the enrollee had a stroke with left hemiparesis. The enrollee has three approved power
options on the wheelchair (tilt, recline and elevating leg rests). Per an evaluation he has 4/5 strength in the right
limb with normal range of motion. He is independent with toilet and tub transfers. He continues to drive,
completes own grocery shopping, cooking, cleaning and is independent with feeding, grooming and hygiene.
The enrollee's strength and function in the right upper extremity indicates that he can control any power
options through their own individual switches.

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 an expandable control system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 5, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 63047 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 63047 and 22633. Code 63047 is a column II code with a modifier indicator of 1 when billed with column I code 22633. Code 63047 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a Dexcom G6 therapeutic continuous glucose monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says there is no reason the Plan's preferred device, the Freestyle Libre continuous glucose monitor, would not be suitable over the requested Dexcom G6

The Plan follows Medicare rules. Medicare rules say that the Plan may specify preferred brands that they will provide coverage for.

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 a Dexcom G6 therapeutic continuous glucose monitor. Our reviewer says that the Dexcom G6 is not medically necessary over the Plan's preferred device. Our physician reviewer found although a continuous glucose monitor is useful and medically necessary for this patient, there is no reason why the Plan's preferred Freestyle Libre, which has alerts for high and low blood glucose levels, would not be as useful for this patient as a Dexcom G6. Now that the Freestyle Libre has alerts it should suffice from the data provided.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CMT; extraspinal, 1 or more regions (CPT code 98943).

You asked the Plan to pre-approve the service. You say that you have a subluxation need to see the
chiropractor for your pain management. The Plan denied your request. The Plan says chiropractic care is
covered only for manual manipulation of the spine to correct a subluxation.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pre-approve CMT; extraspinal, 1 or more regions (CPT code 98943).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS device.

You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria
have not been met.

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 a CardioMEMS device. Our reviewer
says that the requested items/services are considered medically reasonable and necessary in this case. Our
physician reviewer found given the persistent and severe symptoms and signs of congestive heart failure (CHF)
in this enrollee which appears very sensitive to volume loading conditions, the complexity of the medical
regimen and the failure to prevent acute CHF hospitalization, use of the CardioMEMS device is reasonable and
has clinical data, expert opinion, and approved FDA indications to support its use in selected appropriate
clinical situations like this one. It would therefore meet the medical reasonableness and necessity criteria of the
applicable CMS Section 1862(a) 1(A) rule.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CardioMEMS device have been met. Therefore, we decided that the Plan has
to pre-approve a CardioMEMS device.

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 waive the deductible for the duplex scan provided on October 14, 2020.

You asked the Plan to waive the deductible for the duplex scan. You say that the bill was coded incorrectly. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible that applies towards each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 

The duplex scan you asked the Plan to waive the deductible for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The record shows the duplex scan is considered a radiological diagnostic service. This cost sharing is a contractual obligation that had not been met at the time the duplex scan was received on October 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the duplex scan provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychiatric diagnostic evaluation (CPT
code 90791) provided on November 9, 2020.

You asked the Plan to waive the copayment for the outpatient mental health services. You say that you are
appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan
says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Review of the file show that you received a psychiatric diagnostic
evaluation (CPT code 90791) provided on November 9, 2020. You were asked to pay a $40 copayment for the
outpatient mental health services. Your 2020 EOC states that enrollees must pay a $40 copayment for each
Medicare-covered individual visit. 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 psychiatric
diagnostic evaluation (CPT code 90791) provided on November 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there is no imminent danger to self.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 the requested services are not medically reasonable or necessary. Our physician reviewer found there is no expected improvement in a reasonable period of time, as the enrollee was not showing any dangerousness to self or others. There are not auditory or visual hallucinations, and no aggressive behaviors. There were no withdrawal symptoms. There was a CIWA score of 1. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. The health plan's denial of continued inpatient psychiatric services appears appropriate.

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 an inpatient psychiatric facility for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the criteria for Retacrit have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary. The rules also say Retacrit is subject to the specific
criteria listed in the Medicare rules section for ESA therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that
Retacrit is not medically necessary and reasonable. Our physician reviewer found in this case, this patient with
multiple myeloma has anemia with a hemoglobin of less than 10. There are no labs that rule out other causes
such as iron deficiency and B12 deficiency. The service is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) received January 4, 2021.

You asked the Plan to pay for the endodontic therapy. You say that the root canal was medically necessary to prevent infection. The Plan denied your request. The Plan says there is no coverage for endodontic therapy for you 2021 supplemental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) received January 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 11 routine transportation trip miles.

You asked the Plan to pre-approve additional routine transportation trip miles. You say that the additional
mileage is needed. The Plan denied your request. The Plan says you exhausted your benefit.

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.

We looked at your request, the records in the case file, and the rules. Your request exceeds your benefit limit.
Your 2021 EOC states, "each one-way trip must not exceed fifty (50) miles of driving distance. A trip is oneway
transportation; a round trip is two (2) trips." Therefore, we decided that the Plan does not have to preapprove
an additional 11 routine transportation trip miles.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CT colonography, screening, including image post-processing (CPT code 74263) provided on July 30, 2020.

You asked the Plan to pay for the CT colonography. You say that the virtual colon screenings are considered to be medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare or your Plan.

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 CT colonography have not been met. The NCD pertaining to Colorectal Cancer Screening specifically states that screening CT colonography is a non-covered service. This has been in effect since May 12, 2009. There are no exceptions noted for this non-coverage policy. The Plan only covers colorectal cancer screening exams covered by Medicare. Since this is not a test covered by Medicare, denial of payment for this service was appropriate. Therefore, we decided that the Plan does not have to pay for CT colonography, screening, including image post-processing (CPT code 74263) provided on July 30, 2020.