Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the residential detoxification/rehabilitation services provided on July 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the detox/rehab services. You say that you did not have time to get prior authorization for these services, and you were under the impression the services were paid for. The Plan denied your request. The Plan says the documentation shows that you agreed to pay for these services privately. OON care provided without authorization is not covered by the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the residential detoxification/rehabilitation services provided on July 25, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insulin infusion pump (E0784) provided on October 20, 2020.

You asked the Plan to waive the coinsurance for the insulin pump. You say that you were not aware of the amount of your cost-share at the time of the purchase. The Plan denied your request. The Plan says insulin pumps are durable medical equipment which is subject to a 20% coinsurance.

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 20% coinsurance for durable medical equipment (DME) and related supplies. 

You have been asked to pay $1,020.80 for the insulin pump. The Plan's allowed amount for this pump is $5,104 ($5,104 x 20% = $1,020.80). Therefore, you have been asked to pay 20% coinsurance. An insulin pump falls within the durable medical equipment (DME) and related 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 coinsurance for the insulin infusion pump (E0784) provided on October 20, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiography for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says that a repeat echocardiogram is not supported.
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 services. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found although the enrollee is asymptomatic, he has had a percutaneous repair of his ASD and has a septal
occluder device in his heart. In addition, he had a stroke in 2019 which could be related to a septal occluder
leak. There are reports of very late complications from these devices including device dislodgement causing
cardiac shunting. Because of concerns for a late recurrent leak, perforation or dislodgement and migration of
the device, follow-up echocardiography is recommended by the American Society of Echocardiography
guidelines every 1-2 years in patients with percutaneous septal repairs to reassess the placement of the device.
The last echocardiogram on this enrollee was done in 2018 so this would meet the CMS Rule of section 1862
for medically necessity of the echocardiographic procedure based on recommended guidelines from the major
echocardiography professional society. As this enrollee had instrumentation of his heart with a prosthetic
device, using the echo criteria of "new symptoms" is not the appropriate use of those indications criteria for this
complex cardiac condition which requires lifelong regular follow-up and regular repeat echocardiography.
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 services have been met. Therefore, we decided that the Plan has to preapprove
a transthoracic echocardiography 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on July 1, 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 a valid POS code. 

We looked at the file and Medicare rules. The file shows that the claims were billed with an incorrect POS code. The services were rendered at a skilled nursing facility and should be billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the supplies rendered on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #18 and retainer crowns (D6750) for tooth #'s 17 and 19.
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you need these services provided as soon as possible. The Plan denied your request. The Plan says 3 unit bridges to replace a missing posterior tooth are not covered.
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. The Plan only provides coverage for fixed bridges to replace one anterior tooth, and tooth #18 is a posterior tooth. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #18 and retainer crowns (D6750) for tooth #'s 17 and 19.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the range of motion muscle tests and x-rays provided from June 23, 2020, to August 25, 2020 by an out of network provider.
You asked the Plan to pay for the range of motion muscle tests and x-rays. You say that the tests and x-rays were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the range of motion muscle tests and x-rays provided from June 23, 2020, to August 25, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the sling provided on August 19, 2020.

You asked the Plan to pay for the sling. You say that you received the sling from an in network provider. The Plan denied your request. The Plan says that slings are not covered.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the sling by a contract provider. The file does not show that the Plan provided notice that the sling would not be covered. Under Medicare rules, this means the sling is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the sling provided on August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6010, D6059, D4266, D6011), D6104, D6057).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says consideration of implants to support a full denture requires supporting documentation indicating the inability to retain the denture.
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. The Plan covers the services when the services are medically necessary and reasonable. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found a review of the documentation does not support the need for these services. Replacement of these missing teeth can be accomplished with removable prostheses. There was no documentation indicating that the enrollee could not tolerate a removable prosthesis due to a medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services (D6010, D6059, D4266, D6011), D6104, D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says insulin is not being adjusted based on readings.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the monitor is not therapeutic. He is using a glucometer already. Insulin is used twice daily and there is not enough supportive documentation to suggest frequent adjustments are needed. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this device is considered experimental and investigational.

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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found CPT code L8702 (powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated) (MyoPro Orthosis)is not medically necessary. There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis from conditions such as the enrollee's stroke. Therefore per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), the requested orthosis is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The MyoPro Orthosis is not the most appropriate available supply or level of service for the enrollee in question considering potential benefits to the enrollee. It is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not in widespread use based on scientific evidence and not the standard of care for post stroke hemiparesis. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says none of the criteria has been met.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 stimulator. Our reviewer says that the requested stimulator is not medically reasonable or necessary. Our physician reviewer found there is a past history of hypertension and diabetes. However, the procedure was performed at only 1 level. There is no documentation of any previously failed spinal fusion. She is not a current smoker and notes she quit 30 years ago. X-rays documented on 11/4/20 exam demonstrate that the fusion is progressing well without any evidence of dynamic instability. There has not been a lapse of 9 months since the surgery. Therefore, the request for the electric bone growth stimulator was not medically reasonable or necessary.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for catheter placement provided on April 17, 2020.

You asked the Plan to waive the copayment for catheter placement. You say that you were not informed that you would owe a copayment. 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 $0 copayment for EKG's and diagnostic colorectal screenings and a $95 copayment for all other diagnostic procedures and tests. 

You have been asked to pay a $95 copayment for catheter placement. Catheter placement falls 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 copayment for catheter placement provided on April 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) provided on April 25, 2019.

You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim was submitted after the timely filing deadline.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the psychiatric diagnostic evaluation with medical services was not filed until September 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) provided on April 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the nine additional oral surgery procedures (D7250) provided
on September 8, 2020.

You asked the Plan to pay for the nine additional oral surgery procedures. You say that your dentist advised
they were going to do all teeth at the same time. You say that you were advised that it was covered by your
plan. You also say that you cannot afford to pay back such a big amount. The Plan denied your request. The
Plan says two oral surgery procedures are covered per calendar year. The Plan also says that the frequency limit
has been exceeded.

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 frequency limit for oral surgery
procedures has been exceeded. The record shows that the Plan paid for two oral surgery procedures that you
received on this date of service. Therefore, we decided that the Plan does not have to pay for the nine additional
oral surgery procedures (D7250) provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 21, 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 codes 80307 and G0480 are not supported.

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 80307 is presumptive drug testing, any number of
classes. The definition of code G0480 is definitive drug testing, 1-7 drug classes.

We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, there are no
lab results for the date of service at issue. 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
drug testing rendered on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and coinsurance for an x-ray provided by out-of-network providers on April 7, 2020, to May 18, 2020.

You asked the Plan to waive the copayment for a specialist office visit and coinsurance for an x-ray. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments and coinsurance has been applied.

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 $55 copayment for physician/practitioner services/out-of-network/specialist and a 30% coinsurance for outpatient diagnostic tests/out-of-network. 

You have been asked to pay a $55 copayment for a specialist office visit and a 30% coinsurance of the allowed amount for an x-ray. The amount you are being asked to pay for specialist office visits is $385 ($55 x 7 visits = $385). The amount you are being asked to pay for an x-ray is $10.16 ($33.87 x 30% = $10.16). The total amount you are being asked to pay is $395.16 ($385 + $10.16 = $395.16). A specialist office visit falls within the physician/practitioner services/out-of-network/specialist benefit category and an x-ray falls within the outpatient diagnostic tests/out-of-network 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 office visit and coinsurance for an x-ray provided by out-of-network providers on April 7, 2020, to May 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.

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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, the requested Vertiflex Superion device is not medically reasonable or necessary for treatment of this enrollee's medical condition 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.