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

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (64625).

You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 radiofrequency ablation of the sacroiliac joint. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/ investigational due to the wide variation in efficacy in the peer reviewed literature.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up office visit with the requested out of network (OON) provider.

You asked the Plan to pre-approve a follow-up with an OON provider. You say that you have met with this provider every year following your surgery. The Plan denied your request. The Plan says this provider is no longer contracted with the Plan and this service can be safely provided by an in-network provider.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 cover an OON follow-up. Our reviewer says that it is not medically necessary for this care to be provided outside of the Plan's network. Our physician reviewer found that your last visit with the requested out of network specialist. It was noted that there was no evidence of disease at 3 years, no abnormalities on physical exam, and the bilateral mammogram was reported stable. The note further stated that you should continue with your own monthly exams and contact the office immediately if there are any abnormalities, otherwise, return in one year.

There is no specific clinical rationale for continued OON follow-up. The review has determined that it is not medically necessary for you to continue receiving follow-up care with the requested out of network specialist at this point in your treatment. Your care can be safely transitioned to an in-network provider, and the Plan has indicated that the follow-up has already been approved to be provided with an in-network specialist.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an OON follow-up have not been met. Therefore, we decided that the Plan does not have to pre-approve a follow-up office visit with an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing provided on September 30, 2019.

You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999). You say that the Plan should pay this claim. The Plan denied your request. The Plan says train of four testing is considered a bundled procedure as the cost is included in the cost of the primary procedure.

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 95999 is Unlisted neurological or neuromuscular diagnostic procedure. 

We find that CPT code 95999 is included in the cost of the paid primary procedure. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure (95999) have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing provided on September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-Ray examinations provided on August 7, 2020.
You asked the Plan to waive the copayments for X-Rays. You say that you did not have these X-Rays and the Plan is being charged for services that were not rendered. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $14 copayment for each in-network X-Ray. The record shows that 2 X-Rays were provided to you on this date of service. For one X-Ray you have been asked to pay the $14 copayment, for the other X-Ray you have been asked to pay the allowed amount of $13.45 because this is less than the $14 copayment for an X-Ray. Therefore, your total cost-sharing responsibility is $27.45. You have been asked to pay $14 copayment or less for each X-Ray. X-Rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for X-Ray examinations provided on August 7, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 6, 2020, to November 9, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that care could have been provided at a lower level.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 6, 2020, to November 9, 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 the venipuncture (36415), metabolic panel (80053) and echocardiography (93306) provided on July 7, 2020.

You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the right to recover for services provided to eligible beneficiaries is not extinguished by specific plan requirements. The Plan denied your request. The Plan says the reported revenue code on this type of bill does not grant payment.

The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, these services were not reported with the required revenue code. Therefore, we decided that the Plan does not have to pay for the venipuncture (36415), metabolic panel (80053) and echocardiography (93306) provided on July 7, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for a colorectal screening (G0328) provided on July 14, 2020.
You asked the Plan to pay for the colorectal screening. You say that you would like reconsideration because you do not agree with this denial. The Plan denied your request. The Plan says that this test (82270) was performed on July 13, 2020 during your annual physical examination.
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. Specifically, the Plan has failed to forward evidence that you received a colorectal screening on July 13, 2020. Additionally, the Plan states that there is no claim for this service, indicating that this service has not been paid for by the Plan. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for a colorectal screening (G0328) provided on July 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 waive the copayment for a specialist visit provided on April 8, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you were not informed you would owe a copayment for telehealth services The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $40 copayment for each specialist visit. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r (Current Procedural Terminology (CPT) U0003) provided to the enrollee on August 3, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records. The Plan states review of claims history for this enrollee, and a review of the submitted documentation did not contain evidence of a relationship with the ordering physician as required per Centers for Medicare & Medicaid Services guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code U0003 is not supported in the medical record. There was insufficient information provided to verify if the services are supported. Laboratory Results have not been submitted for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r (Current Procedural Terminology (CPT) U0003) provided to the enrollee on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on September 23, 2020, and September 28, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services you received on September 23, 2020, and September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature for a wheelchair.

You asked the Plan to pre-approve power seat elevation feature. You say that you are unable to reach anything in your home without this lift. The Plan denied your request. The Plan says the denial of authorization for this wheelchair feature is correct, because a power seat elevation feature is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by Medicare because it is not primarily medical in nature. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature for a wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 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 laboratory services rendered on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the physician services. You say that this is the provider closest to the enrollee. The Plan denied your request. The Plan says services provided out of network are not covered except in specific circumstances. There are other providers with the same specialty located near the enrollee.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available within a reasonable distance who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. You say that you were not aware that you could not see this provider. You also say that you feel this was an urgent situation. The Plan denied your request. The Plan says these services were rendered by a provider who has opted out of Medicare. The Plan also says that this was not an urgent or emergent situation.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power assist add-on for a manual wheelchair.
You asked the Plan to pre-approve the add-on. You say that this is medically necessary. The Plan denied your request. The Plan says the additional accessories are not reasonable or necessary.
The Plan must follow Medicare rules. Medicare rules say that an add-on to convert a manual wheelchair to a joystick-controlled power mobility device (E0983) is not covered. Medicare does not allow coverage of a transitioning a manual wheelchair to a power wheelchair. Based on this information, we decided that Medicare rules for coverage of the add-on have not been met. Therefore, we decided that the Plan does not have to pre-approve a power assist add-on for a manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, endodontic therapy, and inhalation of nitrous oxide/analgesia provided on September 14, 2020.
You asked the Plan to pay for the core buildup, endodontic therapy, and inhalation of nitrous oxide/analgesia. You say that you would like these services covered. The Plan denied your request. The Plan says core buildup and endodontic therapy are not covered benefits. The Plan also says that the inhalation of nitrous oxide/analgesia is not covered because the core buildup and endodontic therapy are not covered services.
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, core buildup and endodontic therapy are not among those covered under this benefit. The contract also clearly states that anesthesia is only covered when provided with covered procedures. Since core buildup and endodontic therapy are non-covered services, the inhalation of nitrous oxide/analgesia provided with these services is not covered. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required, endodontic therapy, and inhalation of nitrous oxide/analgesia provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

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 testing is not covered.

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, a cardiovascular risk assessment panel, 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 laboratory services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and sleeve (L2397) provided on August 25, 2020.
You asked the Plan to pay for the orthosis. You say that you would like to request reconsideration. You have attached documentation which supports the fact that the enrollee was treated by the physician. The Plan denied your request. The Plan says the medical records do not support that the enrollee ever having seen the provider. The provider did not present any medical records showing that the prescribing physician ever saw the enrollee.
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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee's chief complaint was chronic pain located in the left knee and right knee. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and sleeve (L2397) provided on August 25, 2020.