Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on July 8, 2019.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians
custom profile. The Plan denied your request. The Plan says the documentation did not include a valid
physician order or medical records.
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 G0483 is definitive drug testing of 22 or more drug
classes. We find that CPT code G0483 is not supported in the medical record. There were insufficient records
that show the tests were needed to identify specific substances that were inadequately detected by a
presumptive drug test. There is no evidence that shows the test was individualized to identify 22 or more
specific non-prescribed medications or illicit substances. The records provided do not document concerns
based on clinical review and judgement. Based on this information, we decided that Medicare rules for
coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for
the definitive drug testing provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950). 
 
You asked the Plan to pre-approve a core buildup. The Plan denied your request. The Plan says that this is not a covered benefit. 
 
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 a core buildup (D2950).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiology services provided on January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for cardiology services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
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 cardiology services provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (W6110). 
 
You asked the Plan to pre-approve the additional trips. You say that you have multiple doctor's appointments that you need to be able to attend. The Plan denied your request. The Plan says this request exceeds the limitation for the transportation benefit. 
 
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. Based on this information, we decided that you have 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 trips (W6110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
March 9, 2020.
You asked the Plan to pay for the assembly and operation of a pump. You say that you would like
reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in
the operating room through the duration of the procedure. The Plan denied your request. The Plan says
payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the surgery provided on October 1, 2019.
You asked the Plan to reduce the copayment for the surgery. You say that you were considered an outpatient
and should only be responsible for a $400 copayment. The Plan denied your request. The Plan says you have
been charged 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 $465
copayment for each day for days 1-4 per admission or per stay basis for each Medicare-covered inpatient stay.
You have been asked to pay a $465 copayment for the surgery. The surgery falls within the "Inpatient hospital
care" benefit category. The medical record shows that you were considered an inpatient for this surgery.
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 reduce the copayment for the surgery provided on October 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 17, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on July 11, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that
the member's primary are physician did not refer these services.
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 lab tests provided on July 11, 2019 by an out of
network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
August 17, 2019 to October 11, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration because a
treatment authorization code is not necessary. The Plan denied your request. The Plan says the billed claim is
for a nonparticipating Home Health provider and a required treatment authorization code was not included.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the
submitted claim does not include the required treatment authorization code. Therefore, we decided that the Plan
does not have to pay for the home health services provided to the enrollee from August 17, 2019 to October 11,
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850.
You asked the Plan to pre-approve Genvisc 850 (J7320). You say that the enrollee has severe pain and needs relief. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Orthovisc and Monovisc
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 850 (J7320). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found there are no documented contraindications to orthovisc or monovisc. Criteria not met. Also, these injections remain experimental. Recent literature shows it does not work. 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 850 (J7320) have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the external female catheter system.
You asked the Plan to pre-approve the external female catheter system. You say that because of your condition
you need this external female catheter system. The Plan denied your request. The Plan says Medicare does not
cover this incontinence system.
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. The medical record does not indicate the condition of permanent
incontinence. This system is not covered by Medicare or the Plan. Based on this information, we decided that
Medicare rules for coverage of external female catheters have not been met. Therefore, we decided that the
Plan does not have to pre-approve the external female catheter system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hot tub (A9270).
You asked the Plan to pre-approve a hot tub. You say that you are appealing the denial of a hot tub with a letter from your doctor stating a hydrotherapy tub is the only course of therapy to help your osteoarthritis as well as fibromyalgia. The Plan denied your request. The Plan says this item is not a covered item under Medicare or the Plan.
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 hot tub (A9270).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a chest x-ray (71045) provided on December 27, 2019. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this code may be billed multiple times in one day. The Plan denied your request. The Plan says that a modifier indicating the service as separate was not used. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits.  
 
We find that CPT code 71045 is supported in the record. Specifically, the chest x-ray was rendered by a different provider with a separate NPI than that which rendered the column I procedure, CPT code 36556. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met. Therefore, we decided that the Plan has to pay for a chest x-ray (71045) provided on December 27, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and addition to
lower extremity orthosis provided on March 18, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397), and addition to lower
extremity orthosis (L2810). You say that the Plan should pay this claim. The Plan denied your request. The
Plan says telemarketing to Medicare enrollees is prohibited.
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 knee orthosis (L1833) and suspension
sleeve (L2397), and addition to lower extremity orthosis (L2810). Our reviewer says that the orthoses are not
medically necessary. Our physician reviewer found the issue is whether the requested orthosis, sleeve, and pad
were medically reasonable and necessary in this case, according to the coverage criteria established by the
LCD.
The documentation in the case file does not support that the requested knee orthosis, suspension sleeve, and
condylar pad were medically reasonable and necessary for the enrollee in this case, according to the coverage
criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on,
the enrollee's knee, and there is no objective documentation of joint laxity.
The items coded L2397 (sleeve) and L2810 (condylar pad) are not separately payable when the base item is not
covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397), and addition to lower
extremity orthosis (L2810) have not been met. Therefore, we decided that the Plan does not have to pay for the
knee orthosis and suspension sleeve, and addition to lower extremity orthosis provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a modular entry ramp (E1399). 
 
You asked the Plan to pre-approve a ramp. You say that the enrollee needs a wheelchair ramp to enter his home  the wheelchair will also improve the enrollee's ability to participate in ADL's and will use it on a regular basis inside the home. The Plan denied your request. The Plan says this item is not covered. 
 
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 modular entry ramp (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on August 12, 2019. 
 
You asked the Plan to pay for the testing services. You say that the services rendered were authorized by the ordering physician. The Plan denied your request. The Plan says the documentation does not support the billed coding. 
 
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 G0481 is definitive drug testing of 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. There were insufficient records that show the tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. There is no evidence that shows the testing services were individualized to identify 8-14 specific nonprescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP cleaner and sanitizer device. 
 
You asked the Plan to pre-approve a CPAP cleaner and sanitizer device. You say that your try to clean your CPAP as much as you can but are not good at it. The Plan denied your request. The Plan says this device is not considered to be durable medical equipment as this is a convenience item not primarily medical in nature. 
 
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 CPAP cleaner and sanitizer device
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildups, including any pins when required (D2950). 
 
You asked the Plan to pre-approve the core buildups. You say that you need the core buildups. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the core buildups, including any pins when required (D2950).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the duplex scan studies provided on
January 30, 2020.
You asked the Plan to reduce the copayments for the duplex scan studies. You say that you do not agree with
the Plan that they denied coverage to your portion of codes 93923 and 93971. You say you should only be
responsible for a $115 for all three services. The Plan denied your request. The Plan says you have been
charged 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 $115
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a freestanding facility (such as a radiology center or medical clinic).
You have been asked to pay a total of $305.55 for the duplex scan studies. The duplex scan studies fall within
the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart below. 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 reduce the copayments for the duplex scan studies provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker, heavy duty, wheeled, rigid or folding, any
type.
You asked the Plan to pre-approve a heavy duty walker (E0149). You say that you require a walker to get up
and down from a seated position. The Plan denied your request. The Plan says you do not meet weight criteria
for this walker.
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. Your recorded weight from May 6, 2020 was under 300 pounds.
Based on this information, we decided that Medicare rules for coverage of a heavy duty walker (E0149) have
not been met. Therefore, we decided that the Plan does not have to pre-approve a walker, heavy duty, wheeled,
rigid or folding, any type.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three core buildups, including any pins when required (D2950 x3), and periodontal scaling and root planing (D4342).
You asked the Plan to pre-approve the core buildups and scaling and planing. The Plan denied your request. The Plan says these services are not covered benefits.
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 core buildups, including any pins when required (D2950 x3), and periodontal scaling and root planing (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is not a covered benefit.
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 the core buildup, including any pins when required (D2950).