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

We decided that the Plan does not have to pay for an eye refraction (92015) provided on December 9, 2020.

You asked the Plan to pay for an eye refraction. You say that you think this service should be a covered benefit,
and you want the Plan to pay. The Plan denied your request. The Plan says you are not covered for this service
when seen by an out-of-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when the provider is in-network.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of an eye refraction have not been met. Specifically, services were provided by an out-of-network
provider. The Plan has contracted providers available to provide these services. We found no exception that
would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for
an eye refraction (92015) provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supply allowance provided on December 19, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor supply allowance. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code.
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, uses insulin with at least three daily injections or 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 the therapeutic continuous glucose monitor supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supply allowance provided on December 19, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a cardiac modulation device.

You asked the Plan to pre-approve the Optimizer Smart Implantable Pulse Generator- Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T). You say that this device is medically necessary for the functional capacity and quality of life improvement. The Plan denied your request. The Plan says that the efficacy of the Optimizer System is still uncertain at this time and not recommended in current guidelines for the treatment of heart failure.

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 the Optimizer Smart Implantable Pulse Generator- Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T). Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the enrollee's limitations, with no other available good clinical alternatives, and based on published data, expert opinion and the approved FDA indications, (and in the absence of a specific CMS NCD or LCD for the device), the use of the Optimizer device in this specific clinical situation would therefore meet the medical reasonableness and necessity criteria of the applicable CMS Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k). 

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 Optimizer Smart Implantable Pulse Generator- Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T) have been met. Therefore, we decided that the Plan has to pre-approve a cardiac modulation 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: 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. You say that without this rehabilitation you will have to be put
back in the hospital. The Plan denied your request. The Plan says the denial of authorization for IRF service is
correct.

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 the complexity of your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the records support
a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 11, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopic shoulder surgery for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show the results of x-rays and detailed picture studies support symptoms and examination results.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Literature does not support the requested surgery without trial and failure of conservative treatment measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for arthroscopic right shoulder surgery with distal claviculectomy including distal articular surface; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release; rotator cuff repair is not medically reasonable or 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopic shoulder surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on
December 9, 2020.

You asked the Plan to reimburse you an additional amount for the eyeglasses. The Plan denied your request.
The Plan says your claim processed with the correct copayment.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan processed the claim with the correct
copayment. Therefore, we decided that the Plan does not have to reimburse you an additional amount for
eyeglasses provided on December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the melanoma assay provided on July 9, 2020.

You asked the Plan to pay for the melanoma assay. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 documentation does not include the final pathology results, just of the initial biopsy results. In addition, the documentation does not support how this testing was going to change the management of the enrollee. This means that the melanoma assay test at issue in this appeal 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 the melanoma assay provided on July 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS system (CPT code(s): 33289 and C2624), for the enrollee.

You asked the Plan to pre-approve the system. You say that the services are necessary. The Plan denied your request. The Plan says that the services are considered experimental and investigational.

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 the system. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has NYHA class III heart failure and was admitted in April 2021, for acute on chronic exacerbation of heart failure associated with a NSTEMI for which he underwent intervention. The device is being requested for its Food and Drug Administration (FDA) approved service for which sufficient evidence exists that it is not experimental or investigational. The requested service is medically necessary and reasonable as defined by Medicare rules. The elements of the coverage rule are satisfied. The requested service is recommended. 

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 system have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS system (CPT code(s): 33289 and C2624), for the enrollee.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says benefits in a less-intensive setting are available.
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 you do not require the intensity of services provided in an IRF. Specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, G0483) provided on July
28, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation
and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting
where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Specifically, the submitted claim was billed with a
laboratory place of service code while the record indicates the member's face-to-face service was rendered in
an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307,
G0483) provided on July 28, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, soft tissue neck; with contrast material(s) (CPT code 70491) and CT, abdomen and pelvis; with contrast material(s) (CPT Code 74177), for the enrollee.

You asked the Plan to pre-approve the CT scans. You say that the scans are necessary. The Plan denied your request. The Plan says that the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT scans. Our physician reviewer found the enrollee had a malignant neoplasm of the head, face, and neck of unknown primary for which the enrollee underwent resection followed radiation in 2019 and 2020. The enrollee's most recent neck CT scan was in September 2020, demonstrated bilateral scattered cervical lymph nodes. No abdominal imaging has been done since 2019. UpToDate indicates that residual lymph nodes not treated with lymphadenectomy should be monitored by CT or magnetic resonance imaging (MRI) of the neck. The frequency of radiographic evaluation will depend on the clinical situation but is generally every three (3) to twelve (12) months for the first two (2) to three (3) years. The enrollee had adenopathy that was not treated by lymphadenectomy. The requested CT scan is medically reasonable and necessary as defined by Medicare rules. The elements of the coverage rules are satisfied. The requested service is recommended. 

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 CT scans have been met. Therefore, we decided that the Plan has to pre-approve CT, soft tissue neck; with contrast material(s) (CPT code 70491) and CT, abdomen and pelvis; with contrast material(s) (CPT Code 74177), for the enrollee.

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 cost share for the arthrocentesis and the Part B drug provided on December 14, 2020.

You asked the Plan to waive the cost share for arthrocentesis and the Part B drug. You say that you have a $0 copayment when you see your primary care doctor. 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 to the arthrocentesis and 20% coinsurance for Medicare Part B drugs.

The arthrocentesis you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the arthrocentesis and 20% coinsurance for Medicare Part B drugs. The Part B drug falls within the "Medicare Part B drugs" benefit category. See chart below.

Date of Service
Service
Allowed Amount
Deductible/Coinsurance
Member Liability

December 14, 2020
Arthrocentesis
$61.75
$750
$61.75

December 14, 2020
Part B drug
$1.33
20%
$0.26

Total
$62.01

This cost sharing is a contractual obligation that had not been met at the time arthrocentesis and the Part B drug was received on December 14, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the arthrocentesis and the Part B drug provided on December 14, 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. You say that you are in need for therapy 3 times a day and still taking medication. The Plan denied your request. The Plan says you do not need an intensive therapy program with multiple visits from a rehab doctor 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient 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.