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

We decided that the Plan has to pre-approve myocardial perfusion imaging (78452).
You asked the Plan to pre-approve myocardial perfusion imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not have new or worsening symptoms so this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that radionuclide imaging is covered for risk assessment of re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years or greater than 2 years since last imaging study. 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 myocardial perfusion imaging. Our reviewer says that the requested service is medically necessary. Our physician reviewer found based on the records, the patient has known stable coronary disease last evaluated with nuclear stress testing more than two years ago. In this circumstance, though the patient is stable with no symptoms, Medicare criteria for coverage have been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe left ankle and knee dynamic splinting.You asked the Plan to pre-approvethedynamic splinting device. You say that you believe that the enrollee would greatly benefit from having Dynasplint apparatus to assist with her standing. The enrollee has not been able to stand or walk since an automobile accident in 2000.The Plan denied your request. The Plan says the requested service is considered investigational and non-covered for the management of chronic contractures.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Dynasplint apparatus have not been met.Therefore, we decided that the Plan does not have to pre-approvethe left ankle and knee dynamic splinting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 4 power wheelchair and accessories.You asked the Plan to provide a replacement Group 4 power wheelchair (K0884) and accessories. You say that your power wheelchair no longer works and a new Group 4 power wheelchair is reasonable and necessary for your health and safety.The Plan denied your request. The Plan says Group 4 power wheelchairs are not covered by Medicare or the Plan.Group 4 power wheelchairs are statutorily not covered by Medicare. Therefore, we decided that the Plan does not have to provide a Group 4 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve canal repair (D3346) for tooth # 8.You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says a nerve canal repair is not a covered service.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 dental service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a nerve canal repair (D3346) for tooth # 8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oxygen services provided on September 29, 2019 by the out of network provider.You asked the Plan to pay forthe oxygen concentrator (E1390). You say that the enrollee wants to continue oxygen services with the out of network provider.The Plan denied your request. The Plan says you did not have prior authorization, there is no current documentation for medical necessity, there is no valid order.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 did not pre-approve the item/service at issue. The physician order was written inApril 2017 for 12 months and is not valid now. 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 oxygen services provided on September 29, 2019 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation for the enrollee.
You asked the Plan to pre-approve additional transportation. You say that the enrollee needs to get to and from radiation treatment. The Plan denied your request. The Plan says your benefit only allows 24 trips for this service.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. The file shows that the enrollee has used 24 trips this year. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Terazosin for the enrollee.
You asked the Plan to pre-approve Terazosin. You say that this is the only medication that has proven to be successful for the enrollee. The Plan denied your request. The Plan says Terazosin to be taken at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Terazosin for the enrollee.
Benefits for Terazosin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-preferred diabetic supplies to be provided to the enrollee.
You asked the Plan to pre-approve the non-preferred supplies. The Plan denied your request. The Plan says the requested items are approved for the 90-day transition period.
Medicare rules say that plans can require enrollees to get care from network providers. The rules say that Medicare Advantage plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.
The requested brand of diabetic test strips in this case is not a preferred brand with the plan. The plan has agreed to pre-approve the requested brand for the first 90 days of enrollment. The Plan has preferred brands available who can provide the items at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve non-preferred diabetic supplies to be provided to the enrollee beyond what has been approved by the plan.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the refraction services (92015) provided on September 16, 2019.
You asked the Plan to pay for the refraction services.. You say that you thought that the insurance covered refraction services The Plan denied your request. The Plan says that per the claim filed these services were non-routine and diagnostic and therefore not covered by the plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one routine vision exam every year (including eye refraction for eyeglasses/contact lenses). Per the health plan contract the refraction is a part of a routine vision exam. The plan has failed to provide records to show that the services provided by the in-network provider was not a routine eye exam.
We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we decided that the Plan's rules for coverage of the refraction services. have been met. Therefore, we decided that the Plan has to pay for the refraction services (92015) provided on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services provided to the enrollee on September 3, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere is evidence of misrepresented services.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 the denied codes is:CPT 88368:Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedureCPT 88377:Morphometric analysis, in situ hybridization (quantitativeor semi-quantitative), manual, per specimen; each multiplex probe stain procedure We find that the denied codes are not supported in the medical record. Specifically, the location of the services cannot be confirmed. There is no evidence that the services were rendered in Houston, Texas, despite the fact that the claims had this address on them. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forlab services provided to the enrollee on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 19, 2019 by an out-of-network provider.
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 services were rendered by a non-participating provider without prior authorization.
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 has network providers available who can provide 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 medical services provided on August 19, 2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says that this is 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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary in this case. You underwent bilateral knee injections on April 1, 2019. Documentation does not include any follow-up provider notes following this date of service. Your response to treatment is not supported. Without the support of the documentation, medical necessity cannot be determined. Our physician reviewer found that your condition does not meet criteria for coverage of Euflexxa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower dentures.
You asked the Plan to pre-approve the requested dentures. You say that your previous dentures no longer fit. The Plan denied your request. The Plan says your contract limits coverage for dentures to once every 5 years.
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 file shows that complete upper dentures (D5110) and partial lower dentures (D5212) were requested. We looked at the file and Medicare rules. The requested dentures were last received on November 10, 2017. These dentures are only covered once every 5 years. Based on this information, we decided that the Plan's rules for coverage of the requested dentures have not been met.
The file also shows that interim partial lower dentures (D5821) were also requested. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve upper and lower dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Flexitouchpneumatic compression device to be provided by the out of network provider. You asked the Plan to pre-approvea replacement Flexitouch pneumatic compression device. You say that the enrollee has had success with this device in the past and now needs a replacement device.The Plan denied your request. The Plan says the enrollee does not have truncal lymphedema and you are an out-of-network provider.Medicare rules say that plans can require enrollees to get care fromnetwork 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 pre-approved care.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 doesnot have to pre-approvethe Flexitouch pneumatic compression device to be provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for drug catheter and infusion pump supplies provided from January 2, 2019 to January 3, 2019.
You asked the Plan to pay for the catheter and infusion supplies (A4221, A4222). You say that the Plan should pay this claim. The Plan denied your request. The Plan says IVIG infusion supplies are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicare it must meet all applicable Medicare statutory and regulatory requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infusion supplies (A4221, A4222) have not been met. Therefore, we decided that the Plan does not have to pay for drug catheter and infusion pump supplies provided from January 2, 2019 to January 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
September 10, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you had no other way to
get to the emergency room. You say that the charge should be dismissed. The Plan denied your request. The
Plan says the copayment applied correctly.
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 $200 per
one-way trip.
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls
within the "Ambulance services" 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 ambulance transport provided on September 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.You asked the Plan to pre-approvethe SNF admission. You say that you are not ready to go home because you live alone and are afraid you will fall.The Plan denied your request. The Plan says medical necessity was not established for the continued stay at the skilled nursing facility.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not havedaily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.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 skilled nursing services have not been met.Although you haveskilled therapy needs, these needs are not on a daily basis. Therefore,we decided that the Plan does not have to pre-approvethe SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does nothave to pay for the medical services provided on September 9, 2019 by an out of network provider.You asked the Plan to pay for the outpatient visit (99213) and tobacco cessation counseling (99406). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the Plan and listed in the Provider Directory.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 has network providers available who can provide 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 medical services provided on September 9, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided to the enrollee on July 3, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided to the enrollee on July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on March 6, 2019.
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 code 13153 is not supported.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 13153 and 14040. Code 13153 is a column II code with a modifier indicator of 1 when billed with column I code 14040. Code 13153 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on March 6, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the first 15 minutes of deep sedation/general anesthesia and subsequent 15 minute increment of deep sedation/general anesthesia provided on May 30, 2019.
You asked the Plan to pay for the deep sedation/general anesthesia services. You say that your dentist stated that your wisdom tooth and molar needed to be removed and referred you to an oral surgeon. You also say that the surgeon applied anesthesia, which is a standard and humane procedure for oral surgery for tooth extractions, and you were surprised that it was not covered. The Plan denied your request. The Plan says that based on your Summary of Benefits, general anesthesia and intravenous sedation is excluded for surgical procedures.
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. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the deep sedation/general anesthesia services have been met. The documentation provided does not include a clear exclusion of the type of anesthesia rendered by this in-network provider. Therefore, we decided that the Plan has to pay for the first 15 minutes of deep sedation/general anesthesia and subsequent 15 minute increment of deep sedation/general anesthesia provided on May 30, 2019.
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.