Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for percutaneous arterial infusion for intracranial thrombolysis with angiography and catheter insertion using fluoroscopic guidance (61645) provided on February 28, 2020.
You asked the Plan to pay for the percutaneous arterial infusion for intracranial thrombolysis with angiography and catheter insertion using fluoroscopic guidance. You say that you would like reconsideration because this service was reported appropriately. The Plan denied your request. The Plan says that CMS does not pay any provider or supplier other than thehospital for services furnished to the beneficiary while an inpatient in hospital.
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the percutaneous arterial infusion for intracranial thrombolysis with angiography and catheter insertion using fluoroscopic guidance have been met. Specifically, this procedure is identified as a physician service and not paid to the facility. Therefore, we decided that the Plan has to pay for percutaneous arterial infusion for intracranial thrombolysis with angiography and catheter insertion using fluoroscopic guidance (61645) provided on February 28, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a PET scan provided by a participating provider.

You asked the Plan to waive the coinsurance for a PET scan. You say that you cannot afford this and would like the Plan to pay for it. The Plan denied your request. The Plan says the correct 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 20% coinsurance for outpatient diagnostic tests/PET scan.

You have been asked to pay a 20% coinsurance of the allowed amount for a PET scan. The total allowed amount is $1,632.61. The total amount you are being asked to pay is $326.52 ($1,632.61 x 20% = $326.52). The correct coinsurance amount has been applied. A PET scan falls within the outpatient diagnostic tests/PET scan 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 a PET scan provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (J0585, 43236).
You asked the Plan to pre-approve Botox injections. You say that the botox injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Botox injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found botox is being used for the treatment of gastroparesis. The requested use is not supported as a Food and Drug Administration (FDA) approved indication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections (J0585, 43236).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81355, 81408, 81479) provided on April 1, 2020.
You asked the Plan to pay for laboratory testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81355, 81408, 81479) provided on April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with a non-network provider.

You asked the Plan to pre-approve these services. You say that you need to see this specialist. The Plan denied your request. The Plan says services from a non-participating provider 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. The Plan covers supplemental dental benefits from a network provider only. 

We looked at the file and the Plan's rules. The file shows that you are requesting dental services from a provider who is not a network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services with a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the additions to lower extremity orthoses coded K0672, L2397, L2800, and L2810 provided on February 3, 2020.
You asked the Plan to pay for the additions to lower extremity orthoses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted does not indicate that the provider discussed the need for the billed supply codes. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the additions to lower extremity orthoses coded K0672, L2397, L2800, and L2810 provided on February 3, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ruxience.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has stage III chronic kidney disease. There are no randomized trials to guide the optimal therapy in patients with fibrillary glomerulonephritis or immunotactoid glomerulopathy who have abnormal kidney function or nephrotic range protenuria, and no immunosuppressive therapies have been clearly shown to be beneficial. The use of rituximab (Ruxience) is considered a standard of care. The service is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve Ruxience.

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on November 26, 2019.
You asked the Plan to pay for the physician service. You say that the enrollee revoked hospice services on arrival to the emergency room with the desired code status to be full code. 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 initial hospital care provided on November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services (64635, 64636).

You asked the Plan to pre-approve radiofrequency ablation. You say that the requested services are a medical necessity. The Plan denied your request. The Plan says the requested services are not reasonable and 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 pre-approve radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee had RF ablation of the lumbar medial branches and then had intra-articular facet injections. The request is for repeat RF ablation. The RF ablation did not provide at least 6 months of pain relief. Therefore, the requested procedure does not meet Medicare criteria and is deemed 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services (64635, 64636).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on March 17, 2020.
You asked the Plan to pay for the physician service. You say that the services 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. 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 March 14, 2020. The services in question were provided before the end of that month. Additionally, the record shows that the enrollee re-enrolled in hospice on March 19, 2020. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing (G2024, U0003) provided on July 24, 2020.
You asked the Plan to pay for COVID-19 testing. You say that that these were valid codes for the date of service billed. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and Medicare rules. The submit records do not include documentation that shows the ordering physician was treating the beneficiary. Based on this information, we decided that Medicare rules for coverage of COVID-19 testing have not been met. Therefore, we decided that the Plan does not have to pay for COVID-19 testing (G2024, U0003) provided on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical xray
(D0220), the additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided
on October 13, 2020.
You asked the Plan to pay for the dental services. You say that the provider in this case is in network. You say
that when you made this appointment, you were never told that there would be any fee(s) associated with an
initial visit. You say that you will not pay for these services. You also say that the dental coverage is
inconsistent with what the plan representatives advise or can explain. The Plan denied your request. The Plan
says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-rays are not listed
as covered services. The Plan says that unspecified preventive service is not listed as a covered service either.
The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider
eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation (D0140), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230),
and the unspecified preventive service (D1999) provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 Intravenous Sedation (D9241), 2 Endosteal Implants (D6010), Osseous surgery - 3 teeth per quad (D4261), Bone Replacement Graft, First Site (D4263), Bone Replace Graft, each additional (D4264), biologic materials to aid in soft and osseous tissue regeneration (D4265), and 6 Extractions, Erupted Tooth or exposed root (D7140) provided on June 1, 2020.
You asked the Plan to pay for the sedation, endosteal implants, osseous surgery, bone replacement grafts, biological materials and tooth extractions. You say that the services were medically necessary and you were told they would be covered in part. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the 2 Intravenous Sedation (D9241), 2 Endosteal Implants (D6010), Osseous surgery - 3 teeth per quad (D4261), Bone Replacement Graft, First Site (D4263), Bone Replace Graft, each additional (D4264), biologic materials to aid in soft and osseous tissue regeneration (D4265), and 6 Extractions, Erupted Tooth or exposed root (D7140) provided on June 1, 2020.
Your complaint about potentially receiving misinformation from a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens upgrades (V2750, V2781) and deluxe frames (V025) provided on October 23, 2020.
You asked the Plan to pay for lens upgrades and deluxe frames. You say that you were told that any glasses would be covered. The Plan denied your request. The Plan says only standard glasses are covered.
The Plan must follow Medicare rules. The rules say that Medicare one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL. We looked at the file and Medicare rules. Lens upgrades and deluxe frames are not considered conventional eyeglasses. The record shows that the Plan paid for standard lenses and frames with a $40 copayment in accordance with the contract. Based on this information, we decided that the Plan's rules for coverage of lens upgrades and deluxe frames have not been met. Therefore, we decided that the Plan does not have to pay for lens upgrades (V2750, V2781) and deluxe frames (V025) provided on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology consult to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an OON ophthalmology consult. You say that you need to see this ophthalmologist because you are losing your vision. The Plan denied your request. The Plan says this service is available in-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 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 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 an ophthalmology consult to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal alert system (Life Alert). You asked the Plan to pre-approve Life Alert. You say that you are not steady on your feet, so any time you go outside you are afraid of falling. The Plan denied your request. The Plan says the denial of authorization for this is correct, because Life Alert does not meet the definition of durable medical equipment and is not covered by Medicare. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a personal alert system (Life Alert).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for kyphosis pad, floating (L1030) lumbar-sacral orthotic, full corset (L0976) rib gusset (elastic) L1020) lumbar sling (L1060) sternal pad (L1050) provided July 28, 2020.
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says evidence of misrepresented services.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number. The proof of delivery did not include an order number or details to corroborate the delivery ticket submitted. Of note, the proof of delivery is not itemized to indicate the specific supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for kyphosis pad, floating (L1030) lumbar-sacral orthotic, full corset (L0976) rib gusset (elastic) L1020) lumbar sling (L1060) sternal pad (L1050) provided July 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says there are not complicated wounds or medications which cannot be given in the current location.
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 physician reviewer found that the enrollee was admitted to the acute hospital for pneumonia, sepsis, and respiratory failure after being found unresponsive. His hospital stay was complicated by possible cardiac arrest, respiratory failure requiring intubation and mechanical ventilation. He is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not 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 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.