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

We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network physical therapy visits. You say that you would like to use the out-of-network provider because the plan providers have not helped you. The Plan denied your request. The Plan says there are other network providers available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the lumbar-sacral orthosis (L0650) provided November 20, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary. The Plan denied your request. The Plan says that they did not make a decision and auto forwarded this case.

The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested item was medically necessary and reasonable. Our physician reviewer found that the enrollee is a 75-year-old woman with chronic back pain. The enrollee will continue to follow with her pain management physician. The enrollee's physician notes that the enrollee "would benefit from a back brace to help with immobilization." The documentation supports that the coverage criteria for an LSO as established by the LCD L33790 have been met in this case.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan has to pay for the lumbar-sacral orthosis (L0650) provided November 20, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 17, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 laboratory testing 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 laboratory services provided on September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission provided from September 28, 2020, to October 7, 2020.
You asked the Plan to waive the copayment for the inpatient admission. You say that you disagree with having to pay this amount because it was an emergency, and it was not planned. You say you thought this would be covered. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per day, days 1-6 and a $0 copayment for additional hospital days for each in-network Medicare-covered hospital admission/stay. You have been asked to pay a $325 copayment for each day, days 1-6 of the inpatient admission. ($325 x 6 = $1,950). The inpatient admission falls within the "Inpatient hospital care" 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 the inpatient admission provided from September 28, 2020, to October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment for a previous root canal (D3347).
You asked the Plan to pre-approve the dental service. You say that this service is medically necessary. The Plan denied your request. The Plan says endodontic services 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. Therefore, we decided that the Plan does not have to pre-approve retreatment for a previous root canal (D3347).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14-day sensor kit.
You asked the Plan to pre-approve Freestyle Libre 14-day sensor kit. You say that You feel you would have
better control if you could watch the sugars on the Libre machine. You are presently on oral diabetic medicine.
You are trying to watch it so you don't have to go on the insulin route. The Plan denied your request. The Plan
says the enrollee does not meet the criteria as she does not require more than 3 insulin shots per day, is not on
an insulin pump, is not testing blood sugar at least 4 times per day and does not require frequent changes of
insulin dosing.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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. Based on this information, we
decided that Medicare rules for coverage of Freestyle Libre 14-day sensor kit have not been met. Therefore, we
decided that the Plan does not have to pre-approve Freestyle Libre 14-day sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three retainer crowns (D6751 x3).
You asked the Plan to pre-approve the retainer crowns. You say that you need these retainer crowns to be approved for coverage. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pre-approve three retainer crowns (D6751 x3).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MammaPrint and BluePrint testing services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

The file shows that the enrollee has a diagnosis of left breast cancer. We looked at the file, and Medicare rules. The BluePrint test is a statutorily excluded test. The records do not show that the enrollee has bilateral disease. Based on this information, we decided that Medicare rules for coverage of the requested tests have not been met. Therefore, we decided that the Plan does not have to pre-approve MammaPrint and BluePrint testing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2).
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
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 pre-approve two core buildups, including any pins when required (D2950 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.

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 you do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that BRCA1 and BRCA2 genetic testing is considered medically necessary for a beneficiary with a current diagnosis or a personal history of a cancer associated with the BRCA mutation.

We looked at the file and Medicare rules. The records show that you do not have a personal history of cancer associated with the BRCA mutation. 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 pre-approve BRCA genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories 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 there is no qualifying diagnosis for a group 3 power wheelchair.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:

1. A neurological condition; 

2. Myopathy; or 

3. Congenital skeletal deformity.

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 mobility defect is due to morbid obesity, diabetes mellitus and end stage renal disease with recent COVID-19 infection. The enrollee does not have a neurological disorder that would meet criteria for a group three power wheelchair.

We looked at this physician's review, the file, and Medicare rules. The file does not show a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. 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 group 3 power wheelchair and accessories for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve familial variant targeted sequence testing.
You asked the Plan to pre-approve the requested services. You say that identifying a genetic abnormality could dictate future testing and treatment. The Plan denied your request. The Plan says tests in the absence of signs and symptoms are 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. We looked at the file and the rules. In this case, there are insufficient records to show that the ordered testing is diagnostic, prognostic, or clearly correlates any test result with given interventions. The testing is being 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 pre-approve familial variant targeted sequence testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.
You asked the Plan to pre-approve a wig. You say that the requested item is a necessity for the enrollee. The Plan denied your request. The Plan says rules for DME or prosthetics have not been met.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says you do not meet criteria for the requested device.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose
testing at least four times per day and use insulin with at least three daily injections. Based on this information,
we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan
does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided August 12, 2020.

You asked the Plan to pay for the sedation services. You say that these services were medically necessary. The Plan denied your request. The Plan says this CPT code cannot be paid as billed.

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 99152 is sedation support, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 

We find that CPT code 99152 is not supported in the medical record. Specifically, the record does not clearly show that a trained independent observer was present to assist during the service. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided August 12, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.
You asked the Plan to pre-approve Genvisc. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Genvisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Euflexxa, Durolane, Supartz-FX, and Gelsyn-3 before they will approve the requested drug. In this case, you have not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and A6533.

You asked the Plan to pre-approve the compression stockings. You say that the requested items are medically necessary. The Plan denied your request. The Plan says these items are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 and A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additions to lower limb prosthesis.
You asked the Plan to pre-approve addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and all lower extremity prostheses, flex-walk system or equal (L5981). You say that the additions are medically necessary for stability and support. The Plan denied your request. The Plan says an advanced foot and rotational unit, K3 prosthetic foot is not 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 addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and all lower extremity prostheses, flex-walk system or equal (L5981). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the request appears to exceed the patient's functional need as the documentation indicates the patient is expected to ambulate with a cane, walker, and wheelchair with the requested prosthesis which is not consistent with a K3 level of ambulation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and All lower extremity prostheses, flex-walk system or equal (L5981) have not been met. Therefore, we decided that the Plan does not have to pre-approve additions to lower limb prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee is not checking blood glucose levels four or more times per day. 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 pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of the aorta provided on September 17, 2020.
You asked the Plan to waive the copayment for the duplex scan of the aorta. You say that you had an abdominal aortic aneurysm screening and should have a $0 copayment. You say this was a screening and not a diagnostic test. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $110 copayment for the duplex scan of the aorta. The duplex scan of the aorta falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The medical record shows the duplex scan was performed because of an abdominal aortic aneurysm without rupture which makes the service diagnostic in nature.
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 the duplex scan of the aorta provided on September 17, 2020.