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

We decided that the Plan does not have to pre-approve FreeStyle Libre (K0533) continuous blood glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that the enrollee requires the device. The Plan denied your request. The Plan says they need more information to know if the pump is needed which did not get adequate response.

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 indicates that the enrollee meets coverage criteria, but that the enrollee's diabetes is being currently controlled by a Freestyle Libre CGM. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. We need more information as to why another CGM is needed. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre (K0533) continuous blood glucose monitor (CGM).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan, head or brain, without contrast (70450), and the x-ray of the abdomen (74018) provided on November 7, 2020.

You asked the Plan to pay for the imaging services. You say that the enrollee was not enrolled in hospice on the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on November 23, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan, head or brain, without contrast (70450), and the x-ray of the abdomen (74018) provided on November 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a CT scan provided by a participating provider on February 3, 2020.

You asked the Plan to waive the co-payment for a CT scan. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct co-payments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $105 co-payment for outpatient diagnostic tests/radiological diagnostic services.

You have been asked to pay a $105 co-payment for each CT scan. The total amount you are being asked to pay is $210 ($105 x 2 CT scans = $210). A CT scan falls within the outpatient diagnostic tests/radiological diagnostic services 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 co-payment for a CT scan provided by a participating provider on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you do not have a condition for which Medicare covers compression stockings.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas machine along with subcutaneous vitamin injections provided on September 28, 2020.

You asked the Plan to pay for the Sanexas machine along with subcutaneous vitamin injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the rendered services 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 Sanexas machine along with subcutaneous vitamin injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic pain syndrome, pain of skin, chronic thoracic back pain, cervical radiculopathy, and low back pain. The enrollee reported pain between the shoulder blades, in the neck, trapezius, and left shoulder. A protocol of therapy with RST Sanexas neoGen-Series, combined with the injection of a subcutaneous Nutri-pharmaceutical blend was recommended. The documentation does not support that the use of the Sanexas machine and the administration of subcutaneous vitamin injections provided. Therefore, the enrollee did not meet criteria for the services rendered.

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 Sanexas machine along with subcutaneous vitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas machine along with subcutaneous vitamin injections provided on September 28, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on March 9, 2020.

You asked the Plan to pay for the evaluation and management service. You say that the services that were rendered were medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR) rendered on December 16, 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 the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that TAVR is covered when specific criteria are met.

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found TAVR is indicated for relief of aortic stenosis in patients with symptomatic heart disease due to severe native calcific aortic stenosis who are judged by a Heart Team, including a cardiac surgeon, to be appropriate for the transcatheter heart valve replacement therapy. The records do not support that the enrollee meets the criteria. The TAVR was 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR) rendered on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81455) provided November 18, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not billed with a valid CPT code.

The Plan must follow Medicare rules. Medicare rules say that to report a Comprehensive Genomic Profile, service providers should use CPT code 81479.

We looked at the file and Medicare rules. The test at issue was genetic testing. An unbundled code was used instead of the required CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81455) provided November 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.

You asked the Plan to pre-approve Dupixent. You say that you would like Dupixent to be reconsidered. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.

Benefits for Dupixent 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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 10 speech therapy visits.

You asked the Plan to pre-approve the visits. The Plan denied your request. The Plan says that this is not
medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
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 the visits. Our reviewer says that the
requested speech therapy visits are medically reasonable and necessary. Our physician reviewer found that
there is documentation that the requested therapy is generally accepted as specific and effective therapy for the
enrollee's condition. The unique skills of a professional therapist are required to safely and effectively provide
treatment, that the services can be safely and effectively performed only by a therapist or under the supervision
of a therapist.

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 visits have been met. Therefore, we decided that the Plan has to pre-approve
10 speech therapy visits.

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 pay for the cone beam image capture (D0367), four surgical placements of implant bodies (D6010), a semi-precision attachment abutment (D6052), four bone graft placements (D6104), a radiographic/surgical implant index (D6190) and an implant/abutment supported removable denture (D6111) provided on December 2, 2020, and December 3, 2020, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you do not have the time or energy to deal with this denial. You feel the Plan should cover the services they have committed to cover. The Plan denied your request. The Plan says the services you were provided on the dates in question are not listed as covered services under Medicare or your supplemental dental benefit. These services were also received from an out-of-network provider, and there is no coverage for out-of-network dental care.

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 listed among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam image capture (D0367), four surgical placements of implant bodies (D6010), a semi-precision attachment abutment (D6052), four bone graft placements (D6104), a radiographic/surgical implant index (D6190) and an implant/abutment supported removable denture (D6111) provided on December 2, 2020, and December 3, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 based on the documentation provided, the enrollee is currently undergoing treatment for end-stage pulmonary disease. The enrollee is not intubated or ventilated. There is no evidence that the enrollee requires services that are not currently available or offered by the Plan. The enrollee can remain at the current facility until such time no acute services are required. Medicare coverage criteria are not met. 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panels provided on September 19, 2020.

You asked the Plan to pay for Hereditary cardiomyopathy genomic sequence analysis pane (81439), Molecular pathology procedure (81407, 81408), DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis (81161). You say that the Plan should pay this claim. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels.

The Plan must follow Medicare rules. The rules say that codes 81161, 81407, 81408, 81439 are considered non-covered codes. 

You have requested payment for cardiovascular risk assessment panels. Medicare does not cover or pay for services billed under these codes. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panels provided on September 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the endovenous ablation (36475) provided on September 30, 2019 and October 8, 2019.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the services provided.

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 $20 copayment for each outpatient surgery at a specialist's office.

You have been asked to pay $40 ($20 copayment x 2) for the outpatient surgeries provided at a specialist's office. 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 copayments for the endovenous ablation (36475) provided on September 30, 2019 and October 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 based on the documentation provided, the enrollee is currently undergoing treatment for an abdominal wall wound. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not available at the current facility. Medicare criteria for transfer are not met.

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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code E1399.

You asked the Plan to pre-approve the compression stockings. You say that you need three pairs of compression stockings. The Plan denied your request. The Plan says they have approved compression stockings with the correct code of A6549. The Compression stockings at code E1399 are not a covered item.

The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code E1399.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for ultrasounds (76641, 76700, 76981) provided November 2, 2020 to November 14, 2020.

You asked the Plan to waive the co-payments for the ultrasounds. You say that the co-payments should be waived. The Plan denied your request. The Plan says correct co-payments were applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 co-payment for diagnostic radiology.

You have been asked to pay the Medicare allowable amounts of $142.20, $124.75, $123.10, & $123.10 for a total of $513.15 for the four ultrasounds. the ultrasounds fall within the diagnostic radiology benefit category. The allowable amounts are less than the $160 co-payment listed in the Evidence of Coverage. 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 co-payments for ultrasounds (76641, 76700, 76981) provided November 2, 2020 to November 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the Plan's benefit representative told you the provider was in-network. The Plan denied your request. The Plan says the provider is out-of-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 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 the office visit provided on August 18, 2020 by an out of network (OON) provider.